It is important to remember that TRICARE prohibits the practice of balance billing. Balance billing requirements apply to both network and non-network providers who treat TRICARE beneficiaries, and 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 any amount in excess of the TRICARE allowable charge after TRICARE has processed the claim. This practice is limited by law.
 
Network versus Non-network Provider Responsibilities
Once you’ve signed a contract to become a TRICARE network provider, you’ve agreed to be paid at your contractual rate. If you are a non-network TRICARE authorized provider and have agreed to participate on a particular claim, this means you have agreed to accept the TRICARE-allowable charge as payment in full and not bill patients for any amount in excess of the TRICARE-allowable charge. Non-network providers who do not accept assignment are limited by federal balance billing laws in how much they can bill TRICARE beneficiaries.
 
What if the Patient Has Other Health Insurance?
When other health insurance (OHI) is primary, in most cases TRICARE will pay the benefi ciary liability for covered benefits up to the amount TRICARE would have paid if the beneficiary did not have OHI. If a provider participates with the primary OHI, then all OHI rules and requirements must be followed or TRICARE will not pay the claim.
 
Failure to comply with the balance billing laws is a violation of federal law and is considered fraudulent under the federal laws governing TRICARE. For more information about balance billing, refer to Section 2 of your TRICARE Provider Handbook.