Provider Handbook - Balance Billing

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Balance Billing

A TRICARE network or participating nonnetwork provider contractually agrees to accept the TRICARE-allowable charge as payment in full for a covered service. These providers may not bill TRICARE beneficiaries more than this amount for covered services. Non-network, nonparticipating providers do not have to accept the TRICARE-allowable charge and may bill patients for up to 15 percent above the TRICARE-allowable charge. TRICARE reimburses up to the allowable-charge and beneficiaries are responsible for paying the remainder of the billed amount. If the billed amount is less than the TRICARE-allowable charge, TRICARE reimburses the billed amount.

If a TRICARE beneficiary has other health insurance (OHI), the provider must bill the OHI first. After the OHI pays, TRICARE pays the remaining billed amount up to the TRICARE-allowable charge for covered services. Providers may not collect more than the billed charge from the OHI (the primary payer) and TRICARE combined. OHI and TRICARE payments may not exceed the beneficiary’s liability.

Medicare’s balance billing limitations apply to TRICARE. Non-compliance with balance-billing requirements may affect a provider’s TRICARE and/or Medicare status. Balance billing limitations only apply to TRICARE-covered services. Providers may not bill beneficiaries for administrative expenses, including collection fees, to collect TRICARE payment. Additionally, network and participating non-network providers cannot bill beneficiaries for non-covered services unless the beneficiary agrees in advance and in writing to pay for these services. See “Hold Harmless Policy for Network Providers” later in this section for more information.

For more information about balance billing, visit the Provider Bulletin and Newsletter section or TRICARE's Glossary of Terms.

“An Important Message from TRICARE”

Inpatient facilities are required to provide each TRICARE beneficiary with a copy of the document, An Important Message from TRICARE. This document details the beneficiary’s rights and obligations upon admission to a hospital. The signed document must be kept in the beneficiary’s file. A new document must be provided for each admission.

Last Update: January 15, 2011