TRICARE claims program guidelines

TRICARE (Prime, Standard/Extra)

Network providers must file claims for TRICARE beneficiaries. Non-network providers may accept assignment on a case-by-case basis.

Payment made to network and non-network providers for medical services rendered will not exceed 100% of the TRICARE allowable charge. For non-network providers who do not accept assignment on the claim, beneficiaries will file, however, TRICARE will only allow up to 115% of the TRICARE allowed amount. Hold-harmless and balance-billing rules apply whether network or non-network.

To ensure accurate payment submissions to your provider location, please be sure that you are submitting provider address updates in a timely manner to PGBA. 

Faxed documentation should be submitted to PGBA Provider Data Management at: (803) 462-3986.

Written documentation should be submitted to: 

TRICARE South Region
Provider Data Management Department
PO Box 7039
Camden, SC 29021-7039

Claims for Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA)

CHAMPVA is not a TRICARE program. Find more details about the program including contact information for questions or general correspondence.

Guidelines for the Extended Care Health Option (ECHO)

All claims for ECHO must have a valid written authorization, and the beneficiary must show as enrolled in ECHO in DEERS.

Processing claims for out-of-region care

TRICARE beneficiaries enrolled in a different region will pay the applicable cost-share. Providers then will submit claims based on the TRICARE beneficiary’s enrollment address.

TRICARE for life guidelines

TFL is coverage for TRICARE beneficiaries eligible for Medicare Part A and enrolled in Medicare Part B. Medicare is the primary payer to TFL for all Medicare and TRICARE-covered benefits.

Claims for the Continued Health Care Benefit Program (CHCBP)

Humana Military is the contractor for CHCBP and has partnered with PGBA to process all CHCBP claims. CHCBP beneficiaries may request that providers file medical claims on their behalf.

North Atlantic Treaty Organization (NATO) guidelines

TRICARE covers NATO foreign nations’ armed forces members stationed in the United States or are in the United States at the invitation of the U.S. government. NATO beneficiary eligibility is maintained in DEERS and claims submission procedures are the same as for American ADFMs.

Supplemental Health Care Program (SHCP) claims

The same balance-billing limitations applicable to TRICARE also apply to SHCP.

Claims for the US Family Health Plan (USFHP)

USFHP is a separately funded program that is distinct from the TRICARE program administered by Humana Military.