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.
Department of Veterans Affairs Health Care Facilities
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. If you need care, and a participating VA health care facility near you can provide that care (within the TRICARE access standards), you may be asked to use that VA facility.
TRICARE Provider Types
Figure 2.1
TRICARE-authorized Providers
A provider meets TRICARE’s licensing and certification requirements and has been certified by TRICARE 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 Humana Military to provide care at a negotiated rate. Network providers file claims for you.
Because Humana Military has established networks even in areas far from an MTF, you may have an assigned primary care manager (PCM) from the TRICARE network.
Non-network providers do not have a signed agreement with your regional contractor and are therefore “out of network.”
If you do not have an assigned PCM, you may use any approved TRICARE-authorized, non-network provider for primary (routine) health care services without a referral or prior authorization.
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.
Visiting a participating provider is your best option if seeing a non-network provider.
Nonparticipating providers have not agreed to accept the TRICARE allowable charge or file your claims. Active duty family members who visit nonparticipating providers may be charged up to 15% above the TRICARE allowable charge for services. This amount will not be paid 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.
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 serviceconnected condition is referred to and/or being treated by the VA, the Department of Defense (DoD) is still responsible for payment for the care rendered.
