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Balance Billing (Article 3)
 

Understanding Your Requirements
What is Balance Billing?

Balance billing occurs when a provider bills a TRICARE beneficiary for the remainder of a bill after TRICARE has paid the allowable charge. Network providers sign a contract to be paid at a negotiated rate, while non-network providers who accept assignment, also known as participating non-network providers, agree to accept the TRICARE allowable charge as payment in full.

Network providers and participating non-network providers are prohibited from balance billing.

What if a TRICARE beneficiary also has other health insurance (OHI)?
When OHI is involved, network and participating non-network providers may receive no more than the TRICARE allowable charge through payment by the other health insurer and TRICARE combined. Network providers are required to accept the negotiated rate as payment in full. Participating non-network providers may not collect any amount from a beneficiary after payment of the claim unless TRICARE and the OHI combined have failed to pay the allowable charge. Non-network providers who do not participate in TRICARE, but do participate in OHI, may receive TRICARE payment up to the OHI allowable charge. If the provider does not participate in TRICARE and the OHI, then the provider may bill 115 percent of the TRICARE allowable charge.

What charges are beneficiaries required to pay?

Beneficiary charges appear in the “deductible” or “cost-share” column on the TRICARE Summary Payment Voucher or remittance. Additionally, non-covered services may be billed to the beneficiary only if the beneficiary has agreed in advance and in writing to pay for those services.

TRICARE Prime beneficiaries are only responsible for a copayment when receiving primary, emergency, referred or prior authorized care regardless of whether the provider is network or non-network.

Note: Active duty service members (ADSMs) and their family members enrolled in TRICARE Prime and TRICARE Prime Remote (TPR)/ TRICARE Prime Remote for Active Duty Family Members (TPRADFM) do not have a copayment, except when using the pharmacy benefit, the point-of-service option or if receiving benefits through the TRICARE Extended Care Health Option (ECHO).

Non-compliance with balance billing requirements may affect your TRICARE and/or Medicare status.
 


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