TRICARE defines a provider as a person, business, or institution that provides or gives health care. For example, a doctor is a provider. A hospital is a provider. An ambulance company is a provider. There are many other provider types. A provider must be authorized under the TRICARE regulation and must have their authorized status verified ( certified) by Humana Military.
Note: Active duty service members (ADSMs) and civilian employees of the federal government who are health care providers are generally not authorized to be TRICARE providers in civilian facilities. Only TRICARE-authorized civilian providers may receive reimbursement from TRICARE.
Figure 2.2 provides an overview of various TRICARE provider types.
Corporate Services Provider Class
TRICARE has added a health care provider category to its roster of authorized TRICARE provider types. The Corporate Services Provider Class consists of institutional-based or freestanding corporations and foundations that render professional, ambulatory or in-home care, and technical diagnostic procedures. Some of the specific types of providers who fall within this category may include:
- Cardiac catheterization clinics
- Comprehensive Outpatient Rehabilitation Facilities (CORFs)
- Diabetic outpatient self-management education programs (American Diabetes Association® accreditation)
- Freestanding bone marrow transplant centers
- Freestanding kidney dialysis centers
- Freestanding magnetic resonance imaging (MRI) centers
- Freestanding sleep disorder diagnostic centers
- Home Health Agencies (pediatric or maternity management)
- Home infusion (Accreditation Commission for Health Care accreditation)
- Independent physiological laboratories
- Radiation therapy programs
Certification
Corporate services providers are certified during the application process. Contact PGBA at 1-800-403-3950 for more information.
Corporate services providers must apply to become a TRICARE-authorized provider. Qualified providers can find the Application for TRICARE Provider Status/Corporate Services Provider at PGBA's web site. For corporate services provider conditions for coverage and reimbursement of services, refer to the TRICARE Policy Manual, Chapter 11, Section 12.1 on the TRICARE web site. Military Treatment Facilities
An MTF is a medical facility (hospital, clinic, etc.) owned and operated by the uniformed services— usually located on or near a base. The contracted provider network augments the resources available in the MTF.
Network providers may work closely with MTF providers near them. For an accurate, up-to-date listing of the MTFs in the South Region, use the MTF page or MTF Locator.
MTF Right of First Refusal
MTFs are given the “right of first refusal” for TRICARE Prime beneficiaries residing in a TRICARE Prime Service Area (PSA) of an MTF for referrals for inpatient admissions, specialty appointments, and procedures requiring written prior authorization, providing the MTF has capability to render the service requested by a civilian provider. This means TRICARE Prime beneficiaries must first try to obtain these services at the MTF. The MTF staff will review the referral to determine if they have the specialty capability and an available specialty care appointment within the access standards. The MTF right of first refusal provides the MTF with a unique case mix that helps in maintaining clinical skills of MTF deployable clinical staff. If the service is not available at the MTF within the appropriate access standards, then the beneficiary is referred to a TRICARE network provider.
Veterans Affairs
TRICARE network provider information is given to the Department of Veterans Affairs (VA) and to the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA). VA has the right to directly contact a provider and request care on a case-by-case basis for VA patients or CHAMPVA beneficiaries if the provider is available. The provider is not required to meet access standards for CHAMPVA beneficiaries but is encouraged to do so. The provider rates applicable to the provider’s TRICARE contract do not apply to VA referrals and the provider is free to negotiate with VA. CHAMPVA beneficiaries are not to receive preferential appointment scheduling over a TRICARE beneficiary.
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