When caring for TRICARE beneficiaries, it is important to keep TRICARE’s policies on balance billing in mind. Noncompliance with these requirements can impact your TRICARE and/or Medicare status.
 

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. Both network and non-network providers are prohibited by law from balance billing TRICARE beneficiaries.
 
If you are a network provider, you’ve signed a contract to be paid at the contractual rate. For non-network providers who accept assignment (i.e., agree to participate in TRICARE), you’ve agreed to accept the TRICARE-allowable charge as payment in full.
  
Collecting the beneficiary’s copayment, deductible or cost-share is not considered balance billing.
 

What if a TRICARE beneficiary has other health insurance?  

When other health insurance (OHI) is involved, network and participating, non-network providers may receive no more than the TRICARE-allowable charge through the combined payments of TRICARE and the OHI.

• Network providers must accept the TRICARE contractual rate as payment in full. If the OHI pays more than the TRICARE-allowable charge, no additional TRICARE payment is made.
   
• Participating, non-network providers may not collect any amount from a beneficiary after payment of the claim unless TRICARE and the OHI payments combined have failed to pay the TRICARE-allowable charge. 
   
• Nonparticipating, non-network providers who participate in the OHI may receive TRICARE payments up to the OHI allowable charge.

What charges are beneficiaries required to pay?

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 non-covered services, unless the beneficiary has agreed in advance and in writing to pay for those services.
 
It is highly recommended that TRICARE Prime beneficiaries read and sign the waiver of Non-Covered Services form to acknowledge financial responsibility for non-covered services.
 

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

  
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Created: September 6, 2007