TRICARE defines a provider as a person, business, or institution that provides health care. For example, a doctor, hospital, or ambulance company is a provider. Providers must be authorized under TRICARE regulations and have their status certified by the regional contractors to provide services to TRICARE beneficiaries.
Military Treatment Facilities A military treatment facility (MTF) is a medical facility (hospital, clinic, etc.) owned and operated by the uniformed services—usually located on or near a military base. To locate an MTF near you, visit www.tricare.mil/mtf.
TRICARE Provider TypesFigure 1.1
TRICARE Authorized Providers
A provider who meets TRICARE’s licensing and certification requirements and has been certified byTRICARE to provide care to TRICARE beneficiaries. TRICARE-authorized providers include doctors, hospitals, ancillary providers (laboratories and radiology centers), and pharmacies. If you see a provider who is not TRICARE-authorized, you are responsible for the full cost of care.
There are two types of TRICARE-authorized providers: Network and Non-network.
Network Providers
Non-Network Providers
Network providers have a signed agreement with your regional contractor to provide care at a
negotiated rate. Network
providers file claims for you.
You will receive most of your care from TRICARE network providers
Non-network providers do not have a signed agreement with your regional contractor and are therefore “out of network.” In most cases, you will not receive care from non-network providers unless approved by your regional contractor. You may seek care from a non-network provider in an emergency or if you are using the point of service (POS) option.
There are two types of non-network providers: Participating and Nonparticipating.
Participating
Nonparticipating
Participating* providers have agreed to file claims for you, to accept payment directly from TRICARE and to accept the TRICARE allowable charge less any applicable cost-shares paid by you as payment in full for their services.
Using a participating
provider is your best option if you must visit a non-network
provider.
Nonparticipating providers have not agreed to accept the TRICARE allowable charge or file your claims.If you use the POS option and seek care from a nonparticipating provider, the provider may charge you up to15% above the TRICARE allowable charge for services (in addition to POS fees). This amount is your responsibility and will not be shared by TRICARE.
If you visit a nonparticipating
provider, you may have to pay the provider first and file a claim with TRICARE for reimbursement.
*Providers may decide to participate on a claim-by-claim basis
Department of Vetrans Affairs Health Care Facilitiies Many Department of Veterans Affairs (VA) health care facilities participate in TRICARE as network providers. While VA facilities may or may not provide primary care, many do provide specialty care. Be sure to find out the VA facility’s status as a TRICARE network or non-network provider before you receive TRICARE-covered health care at a VA facility.
Note: Active duty service members who are referred to a VA medical facility for a service-connected condition must receive health care benefits under the VA program. When an active duty service member with a service-connected condition is referred to/being treated by the VA, the Department of Defense (DoD) is still responsible for payment for the care rendered.
Some retired service members may be eligible for both TRICARE and VA benefits (the VA offers health care programs separate from TRICARE—refer to the VA Website for details), so you will have to choose which program you want to use. When choosing between TRICARE and VA benefits, carefully compare the costs and the financial demands of each option to make the best decision.
