Reimbursement limitations

Payments made to network and non-network providers for medical services rendered to beneficiaries shall not exceed 100 percent of the TRICARE allowable charge for the services.

The TRICARE allowable charge is the maximum amount TRICARE will authorize for medical and other services furnished in an inpatient or outpatient setting. For non-network providers, TRICARE will reimburse the lesser of the TRICARE allowable charge or the provider’s billed charge for the service.

For example:

  • If the TRICARE allowable charge for a service from a non-network provider is $90 and the billed charge is $50, TRICARE will allow $50 (the lower of the two charges)
  • If the TRICARE allowable charge for a service from a non-network provider is $90 and the billed charge is $100, TRICARE will allow $90 (the lower of the two charges)

In the case of inpatient hospital services from a non-network provider, the specific hospital reimbursement method applies. For example, the Diagnosis-Related Group (DRG) rate is the TRICARE allowable charge for inpatient hospital services.

In the case of outpatient hospital claims subject to the TRICARE Outpatient Prospective Payment System (OPPS), services will be subject to OPPS ambulatory payment classifications where applicable.

Non-network nonparticipating providers have the legal right to charge beneficiaries up to 115 percent of the TRICARE allowable charge for services.