What is balance billing?

Balance billing is when a provider bills a TRICARE beneficiary for more than their payment responsibility after TRICARE has processed the claim. Network providers sign a contract to be paid at a negotiated rate. Non-network providers who accept assignment, i.e., participate in TRICARE, agree to accept the TRICARE allowable charge as payment in full. Collecting the beneficiary’s copayment, deductible, or cost-share is not considered balance billing.

All providers are prohibited from balance billing.

What if a TRICARE beneficiary has other health insurance (OHI)?

When OHI is involved, network and participating nonnetwork providers may receive no more than the TRICARE allowable charge through payment by the other health insurer and TRICARE combined.
 

• Network providers must accept the TRICARE negotiated rate as payment in full. If the OHI pays more than the TRICARE allowed amount, no additional TRICARE payment will be made.
     
• 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.
     
• Nonparticipating, non-network providers who participate in the OHI may receive TRICARE payment up to the OHI allowable charge. If the provider does not participate in TRICARE or the OHI, then the provider may bill up to 15 percent above the TRICARE allowable charge. The beneficiary should not be charged a cost-share when the Explanation of Benefits shows no patient responsibility.

In most cases, the patient is not required to pay the copayment, cost-share or deductible when TRICARE is a secondary payer. Beneficiary charges appear in the “deductible” or “cost-share” column on the TRICARE Summary Payment Voucher or remittance.

Network and non-network providers who sign participation agreements with “hold harmless” provisions may not bill the beneficiary for noncovered services, unless the beneficiary has agreed in advance and in writing to pay for those services. Some of these providers include hospices, certified marriage and family therapists, partial hospitalization programs, residential treatment centers, substance use disorder rehab facilities and birthing centers.

TRICARE Prime beneficiaries must read and sign the Request for Non-Covered Services form to be considered financially responsible for non-covered services.

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

Note: Active duty service members and their family members enrolled in TRICARE Prime and TRICARE Prime Remote/TRICARE Prime Remote for Active Duty Family Members 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.

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Last Reviewed:  February 1, 2007