Balance Billing
A term used to describe when a provider bills a beneficiary for the difference between billed charges and the TRICARE allowable charge after TRICARE (and other health insurance) has paid everything it’s going to pay. Participating providers are prohibited from balance billing. Nonparticipating providers may charge up to 15 percent above the TRICARE allowable charge.
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Non-network Provider
Non-network providers do not have a signed agreement with your regional contractor and are therefore “out of network.” You are using the TRICARE Standard option when you visit a non-network provider. There are two types of non-network providers: participating and nonparticipating. |
Beneficiary Counseling and Assistance Coordinator (BCAC)
Persons at military treatment facilities and TRICARE Regional Offices who are available to answer questions, help solve health care-related problems, and assist beneficiaries in obtaining medical care through TRICARE. To locate a BCAC near you, visit the TRICARE Web site.
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Nonparticipating Non-network Provider
Nonparticipating providers have not agreed to accept the TRICARE allowable charge or file your claims. Nonparticipating providers may charge you up to 15 percent above the TRICARE allowable charge for services. This amount is your responsibility and will not be shared by TRICARE. |
Catastrophic Cap
The maximum out-of-pocket expenses for which TRICARE beneficiaries are responsible for deductibles and cost-shares based on allowed charges for services and supplies received in a given fiscal year (October 1-September 30).
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Other Health Insurance (OHI)
Any non-TRICARE health insurance that is not considered a supplement acquired through an employer, entitlement program, or other source. TRICARE pays second after all other health plans except for Medicaid, TRICARE supplements, the Indian Health Service, or other programs or plans as identified by the TRICARE Management Activity.
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Continued Health Care Benefit Program (CHCBP)
A premium-based health care program you may purchase after loss of TRICARE eligibility if you qualify. The CHCBP offers temporary transitional health coverage and must be purchased within 60 days after TRICARE eligibility ends.
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Participate on a Claim
When providers participate on a claim, also known as “accepting assignment,” they agree to file the claim for the patient, to accept payment directly from TRICARE, and to accept the amount of the TRICARE allowable charge, less any applicable patient cost-share paid by you, as payment in full for their services.
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Cost-share
A cost-share is the percentage or portion of costs that the beneficiary will pay for inpatient or outpatient care.
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Participating Non-network Provider
Participating providers have agreed to file claims for you, to accept payment directly from TRICARE, and to accept the TRICARE allowable charge plus applicable cost-shares paid by you as payment in full for their services. Providers may participate on a claim-by-claim basis.
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Debt Collection Assistance Officer (DCAO)
Persons located at military treatment facilities and TRICARE Regional Offices to assist you in resolving health care collection-related issues. Contact a DCAO if you have received a negative credit rating or have been sent to a collection agency due to an issue related to TRICARE services.
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Prior Authorization
A review determination made by a licensed professional nurse or paraprofessional for requested services, procedures, or admissions. Prior authorizations must be obtained prior to services being rendered or within 24 hours of an admission. Contact Humana Military for a list of services requiring prior authorization.
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Defense Enrollment Eligibility Reporting System (DEERS)
A database of uniformed services members (sponsors), family members, and others worldwide who are entitled under law to military benefits, including TRICARE. Beneficiaries are required to keep DEERS updated.
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Regional Contractor
A TRICARE civilian partner who provides health care services and support in the TRICARE regions (Health Net Federal Services, Inc.; Humana Military Healthcare Services, Inc.; and TriWest Healthcare Alliance). |
Explanation of Benefits (EOB)
A statement sent to beneficiaries showing that claims were processed and the amount paid to providers. If denied, an explanation of denial is provided.
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Transitional Assistance Management Program (TAMP)
Transitional health care for certain uniformed services members (and eligible family members) who separate from active duty. |
Military Treatment Facility (MTF)
A military treatment facility is a medical facility operated by the military.
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TRICARE Allowable Charge
The maximum amount TRICARE will pay for services. |
Negotiated Rate
The rate network providers and participating non-network providers have agreed to accept for covered services.
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TRICARE-authorized Provider
A provider who meets TRICARE’s licensing and certification requirements and has been certified by TRICARE to provide care to TRICARE beneficiaries. If you see a provider who is not TRICARE-authorized or can never be certified, you are responsible for the full cost of care. TRICARE-authorized providers include doctors, hospitals, ancillary providers (such as laboratory and radiology providers), and pharmacies. There are two types of TRICARE-authorized providers: network and non-network.
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Network Provider
Network providers have a signed agreement with your regional contractor to provide care at a negotiated rate. Network providers handle claims for you. You are using the TRICARE Extra option when you visit a network provider. |
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TRICARE Supplement
A health plan you may purchase specifically to supplement your TRICARE Standard and TRICARE Extra coverage. It will pay second after TRICARE. A TRICARE supplement is not employer-sponsored health insurance. |
