Please note: Network providers are required to submit claims on your behalf. If the provider who rendered services is a network provider, please follow-up with them to have your claims submitted.
Disclaimer: Using non-network providers
Attach a readable copy of the provider's bill to the claim form, and make sure it contains the following information:
IMPORTANT:Please ensure that the patient’s name and sponsor’s name, as well as the Sponsor's Social Security Number (SSN) or Department of Defense Benefits Number (DBN) (eligible former spouses should use their SSN) are on ALL attachments.
If you need to file a claim for care you received overseas, you must file the claim with the overseas claims processor using the address for the area where you got the care. Learn more
All TRICARE claims are subject to TRICARE Maximum Allowable Charge (TMAC). Tied by law to Medicare’s allowable charges, TMAC is the maximum amount TRICARE will pay a doctor or other provider for a procedure, service or equipment.
Please note: ‘TMAC’ may also be referred to as CHAMPUS Maximum Allowable Charge or (CMAC).
Non-participating providers can charge you up to 15% more than TMAC, known as balance billing. If you use a non-participating provider, you will have to pay all of that additional charge up to 15%. See TRICARE.mil/Costs/Cost-Terms for additional information.
All TRICARE-authorized providers meet TRICARE licensing and certification requirements and are certified by TRICARE to provide care to TRICARE beneficiaries. TRICARE-authorized providers may include doctors, hospitals, ancillary providers (e.g., laboratories, radiology centers) and pharmacies that meet TRICARE requirements. If you see a provider that is not TRICARE-authorized, you are responsible for the full cost of care. Find a list of TRICARE-authorized providers
Network providers are contractually required to submit claims for beneficiaries for services rendered. Beneficiaries cannot file a claim themselves for services rendered by a network provider.
Network providers may accept copay/cost-share from beneficiaries prior to services rendered (beneficiaries should not pay up-front for services rendered by a network provider unless it is their copay/cost-share).
Non-network providers do not have a signed agreement with TRICARE and are considered out-of-network.
There are two types of non-network providers: participating and nonparticipating.
Participating non-network providers may choose to participate on a claim-by-claim basis. They have agreed to accept payment directly from TRICARE and accept the TMAC (less any applicable patient costs paid by beneficiary) as payment in full.
For nonparticipating non-network providers, beneficiaries may have to pay up-front for services rendered and file their own claim. These providers have not agreed to file your claim. The providers also have a legal right to charge up to 15% above the TRICARE-allowable charge for services (beneficiaries are responsible for paying this amount in addition to any applicable patient costs).
Please note: If a provider is not TRICARE-authorized/certified on the date services are rendered, the claim will deny. If the provider does not complete and submit certification paperwork, the beneficiary will be responsible for all charges.
You should expect to file your own claims to get money back if you have TRICARE Overseas Program (TOP) Select. You don’t need to file claims when using the US Family Health Plan. If you’re unsure about how your claims will be filed, check with your provider to find out if you need to submit a claim after receiving care.Learn more