Network providers may only bill TRICARE beneficiaries for applicable deductible, copayment, or cost-sharing amounts, but may not bill for charges that exceed contractually agreed-upon payment rates. Because network providers have contractually agreed to adhere to these provisions, TRICARE beneficiaries will be referred first to a network provider. The beneficiary’s responsibility is reflected on the explanation of benefits (EOB) or the provider’s remittance advice. In the case of a network provider, the contractually negotiated amount is the TRICARE-allowable charge.
Non-network providers who accept assignment are limited to collecting the TRICARE-allowable charge. If the billed charge is less than the allowable charge, the billed charge becomes the billable amount to the beneficiary. Balance billing applies only to services covered by TRICARE.
When providers do not accept assignment on a claim, non-network, nonparticipating providers can collect applicable deductibles and/or cost-shares and any outstanding amounts up to 15 percent above the TRICARE-allowable charge (shown on the TRICARE EOB) from a TRICARE Standard beneficiary. If the billed charge is less than the TRICARE-allowable charge, the billed charge is the allowable amount used to process the claim.
Balance billing applies only to services covered by TRICARE. TRICARE’s balance-billing limit also applies when other health insurance (OHI) is involved. Providers may not bill beneficiaries for administrative expenses, including collection fees, to collect TRICARE amounts.
Balance Billing and OHI
Providers are limited to collecting the amount previously described, regardless of the beneficiary’s OHI financial responsibility. When OHI is involved, the provider of care may receive no more than the TRICARE-allowable charge, or if a non-network, nonparticipating provider, 115 percent of the TRICARE-allowable charge through payment by the OHI and TRICARE. 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 TRICARE-allowable charge. In the case of a network provider, the contractually negotiated amount is the TRICARE-allowable charge. Additionally, network providers cannot bill beneficiaries for non-covered services unless the beneficiary has agreed in advance and in writing to pay for these services. See “Hold Harmless Policy” later in this section.
Non-compliance with these balance-billing requirements by any TRICARE provider may affect that provider’s TRICARE and/or Medicare status. Additional information on this topic may be obtained by visiting TRICARE's web site.
Urgent and Emergency Care
In urgent and emergency situations, a preliminary report of a specialty consultation should be submitted by the network provider to Humana Military within 24 hours. Telephone reports to the MTF can be coordinated based upon the urgency of the condition. Please be sure to also fax the report to Humana Military for completion of electronic records. Refer to the Medical Coverage section of this handbook for more information on emergency and urgent care services.
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