I have heard many people complain about a particular doctor’s bill not being covered by TRICARE. Diving deeper into the problem, it is invariably because the patient did not have a clear understanding of network vs. non-network providers, but also, and perhaps more importantly, they did not know the difference between participating and non-participating providers.
Here’s a quick summary of these terms – it may help you avoid a surprise bill after your next visit.
Network Providers: The Most Affordable Option
Network providers are TRICARE-authorized institutions or individuals that have signed a contract with your regional contractor. Not only are they credentialed or licensed in their field, but they also have been certified by TRICARE to provide care. These providers have also agreed to accept the TRICARE-negotiated rate as payment in full.
[RELATED: MOAA’s 2021-22 TRICARE Guide]
If you have TRICARE Select and go to a network provider, you should not have to file a claim and you should not have to pay anything above your copayment or cost share.
Non-Network Providers: Where It Can Get Tricky
You may see non-network providers when you are using TRICARE Select, TRICARE Reserve Select, TRICARE Retired Reserve, or TRICARE Young Adult-Select, or if you are enrolled in TRICARE Prime Remote and there are no network providers available in your remote location.
What’s confusing is that there are actually two types of non-network providers: those who participate – meaning they accept the TRICARE allowable charge as payment in full for their services – and those who are non-participating, meaning that they do NOT accept the TRICARE allowable charge and have the legal right to charge up to 15% more than the TRICARE allowable charge.
If you get care from a non-participating, out-of-network provider, you are responsible for any charges above the TRICARE allowable charge, and no percentage of those excess charges goes toward your annual catastrophic cap. You may have to pay out of pocket and then file a claim with TRICARE yourself.
Seeing a participating non-network provider for your health care is going to be by far the easier and more affordable of the two options: You will not have to file claims, and your out-of-pocket costs are going to be limited to your copayment/cost share.
[TRICARE.MIL: Non-Network Providers]
Ask the Right Questions
Before you see a new provider, don’t simply ask whether they “take” TRICARE. Ask them whether they accept your TRICARE plan and are a network provider.
If you visit a provider that is non-network and non-participating, be prepared to pay more out of pocket and have to do a little more legwork.
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