Thank you for your interest in becoming a provider for the TRICARE South Region! Please read this overview to learn more about the process.
What does it mean to be a TRICARE provider?
TRICARE defines a provider as a person, business or organization that provides health care. All TRICARE providers must be authorized/certified under TRICARE regulation and must have that authorized/certified status verified in the South Region.
As the health care program for active duty and retired members of the uniformed services, their families and survivors, TRICARE supplements the health care resources of the Army, Navy, Air Force and Coast Guard with civilian health care professionals to provide timely access and high-quality service.
The program is available worldwide in six separate TRICARE regions — TRICARE North, TRICARE South, TRICARE West, TRICARE Europe, TRICARE Pacific and TRICARE Latin America/Canada — managed jointly by the TRICARE Management Activity (TMA) and TRICARE Regional Offices.
Humana Government Business
(d.b.a. Humana Military)
As the civilian Managed Care Support Contractor (MCSC), Humana Military serves more than 2.9 million TRICARE beneficiaries in the South Region, which includes Alabama, Arkansas, Florida, Georgia, Kentucky (only the Fort Campbell area), Louisiana, Mississippi, Oklahoma, South Carolina, Tennessee and Texas (excluding the El Paso area).
Humana Military's partners include:
- PGBA, LLC: As Humana Military's claims processing partner in the South Region, PGBA is a fiscal intermediary for the military's TRICARE health benefits program and is one of the largest subsidiaries of BlueCross BlueShield of South Carolina. As the claims processor, providers must go through PGBA in order to become certified.
- ValueOptions, Inc.: As Humana Military's behavioral health partner in the TRICARE South Region, ValueOptions is the nation's largest independent behavioral health care and wellness company, specializing in management for all behavioral health issues and mental health and chemical dependency diagnoses.
The information included here defines a “TRICARE” certified provider as one who is authorized to provide services and submit claims for TRICARE beneficiaries…this is not the same as a network provider. A TRICARE network provider is one who has been certified for TRICARE and also has a contract with (HGB/Humana Military) accepting a discount off of the fee schedule and following specific compliance rules defined for network providers. Providers can request to “Join the Network” once they are certified.
TRICARE-Certified Providers vs. TRICARE-Contracted Providers
A TRICARE-certified provider
is a person, business or organization that meets the licensing and certification requirements of TRICARE regulations and practices for that area of health care. Providers must be TRICARE-certified through PGBA, Humana Military's claims processing partner, in order to file claims and receive payment for TRICARE services.
TRICARE-certified providers may or may not agree to "accept assignment," which means accepting the TRICARE Maximum Allowable Charge (TMAC) as payment in full for services. Providers that do not agree are considered authorized, nonparticipating providers, also known as TRICARE-certified, non-network providers. These providers may elect to accept assignment on a claim-by-claim basis.
A TRICARE-contracted provider
is a TRICARE provider who has been certified that has a contract agreement with Humana Military. Also known as authorized, participating network providers, TRICARE-contracted providers agree to accept the TMAC minus any agreed-on discount as payment in full and to submit claim forms for beneficiaries.
How to Become TRICARE-Certified
In order to submit claims, providers must become TRICARE-certified by submitting the appropriate form to PGBA. Visit myTRICARE.com
, click Provider Forms at the bottom of the page and then select Provider Certification from the left-hand list of forms.
Choose the appropriate application by reviewing the descriptions — Individual, Group, Supplier, Institutional or Corporate Service Provider — and follow the directions on the form.
How to Become a TRICARE Network Provider
If you are interested in becoming a network provider, you must be willing to agree to a discount off the 100 percent TRICARE Maximum Allowable Charge (TMAC) as well as billed charges if no TMAC exists. You must also agree to submit all TRICARE claims electronically.
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