TRICARE beneficiaries have many options for selecting health care providers. Knowing their providers' TRICARE category can help beneficiaries make the right choice, and save them money. TRICARE terms used in reference to providers include "authorized," "participating," "non-participating," "network" and "non-network."

Types of Providers

TRICARE-Authorized Providers:

TRICARE-authorized providers must be licensed by their state, accredited by a national organization (if one exists) and meet other standards of the medical community. Additionally, they must fall into one of the categories of health care centers (facilities) or individual providers described below. The TRICARE regional contractors must certify the providers' authorized status before they can pay for covered services received from providers. TRICARE-authorized providers are issued a TRICARE provider number that enables them to file claims to TRICARE for services they provide to TRICARE beneficiaries. Beginning Sept. 1, 2004, all Medicare-certified providers who are recognized as a provider class under TRICARE are considered TRICARE-authorized providers.

Individual TRICARE-Authorized Providers:

Individual TRICARE-authorized providers include: attending physicians, certified nurse practitioners, clinical nurse specialists (if approved in the state in which they work), certified psychiatric nurse specialists, Christian Science practitioners and nurses (if currently listed in the Christian Science Journal), dentists (DDSs or DMDs), independent laboratories, medical equipment and supply firms, most clinical psychologists (with Ph.D.s or Psy.D.s), physician assistants, podiatrists and optometrists.

Individual TRICARE-authorized providers may refer beneficiaries for specialty care. TRICARE will cost share covered services from the following types of providers (only if the referring provider's name is shown on the claim form): audiologists, licensed practical nurses, mental health counselors, nurse anesthetists, occupational therapists, pastoral counselors, physical therapists, radiologists, registered nurses and speech therapists.

TRICARE-Authorized Health Care Centers (Facilities):

TRICARE-authorized facilities include: hospitals, college or university infirmaries, Medicare-certified skilled nursing facilities (not including retirement homes or homes for the aged) and Christian Science sanatoriums that are a part of the First Church of Christ, Scientist. Also included are some ambulatory surgery centers, some birthing centers, some residential treatment centers and some special treatment centers.

Some facilities, such as outpatient rehabilitation facilities, birthing centers, pain treatment facilities, mental health clinics, residential treatment centers and eating disorder clinics may not be TRICARE-authorized providers, or the services they provide may not be covered benefits. Beneficiaries should contact the regional contractor, a TRICARE service center (TSC) or a local beneficiary counseling and assistance coordinator (BCAC)) for assistance. A BCAC directory is available online at www.tricare.osd.mil/beneficiary/beneficiary/BCACDirectory.htm.

Network Provider:

TRICARE network providers are those TRICARE-authorized providers who enter a contractual agreement with the TRICARE regional contractor to provide health care to TRICARE Prime or TRICARE Extra beneficiaries. They agree to accept TRICARE negotiated rates, which are usually less than the TRICARE maximum allowable charge (TMAC), as the full fee for the services they render, and they file claims for the beneficiaries.

Non-network Provider:

Non-network providers are those TRICARE-authorized providers who do not have a contractual agreement with the TRICARE regional contractor to provide care to TRICARE beneficiaries. Care received from a non-network provider may result in expensive point-of-service charges for TRICARE Prime beneficiaries and higher cost shares for beneficiaries under TRICARE Standard. There are two types of non-network providers:

1. Participating Providers: Providers who participate in TRICARE (participation is also referred to as accepting assignment) agree to accept the TRICARE allowable charge as the full fee for services they render including the beneficiary's cost-share and deductible, if any. Individual providers may participate on a case-by-case basis. Hospitals that participate in Medicare, by law, must participate in TRICARE for inpatient care. For outpatient care, hospitals may participate on a case-by-case basis. A participating provider will normally file TRICARE claims for beneficiaries.

2. Non-participating Providers: Non-participating providers do not agree to accept the TRICARE allowable charge as the full fee for services they render. A non-participating provider may charge up to 15 percent above the TRICARE allowable charge for services, and beneficiaries who receive care from non-participating providers are responsible for those additional charges. A non-participating provider may or may not file TRICARE claims for beneficiaries. Beneficiaries may be responsible for paying for the services from a non-participating provider first, then for filing their own claims with TRICARE to receive reimbursement. TRICARE will not provide reimbursement for the additional charges above TRICARE allowable charge.

Receiving Care from Providers NOT Authorized by TRICARE:

Beneficiaries who choose to receive medical care from providers who are not TRICARE-authorized may be responsible for all billed charges. Providers who are interested in becoming a TRICARE-authorized provider should contact a regional provider relations representative:

TRICARE North - www.healthnetfederalservices.com
1-877-TRICARE (1-877-874-2273)

TRICARE South - www.humana-military.com
1-800-444-5445

TRICARE West - www.triwest.com
1-888-TRIWEST (1-888-874-9378)

For More Information:
Beneficiaries may determine if their provider participates in TRICARE, or if their provider is authorized by TRICARE by asking their provider, by contacting their regional contractor, or by visiting the TRICARE Web site at www.tricare.osd.mil.