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TRICARE Provider Types: Understanding Your Options

5/9/2018

You can visit several types of providers when you need care, regardless of your TRICARE plan. It’s important to understand your provider options because who you see impacts both your out-of-pocket costs and filing a claim. Take command of your health and your TRICARE health care benefit by learning about your provider options.

With TRICARE, a provider is a person, business, hospital or pharmacy that provides health care. At a minimum, TRICARE must authorize and certify all providers. The regional contractors must also verify them. This approval process makes them TRICARE-authorized providers. If you see a provider that isn’t TRICARE-authorized, you’ll pay the full cost of care (an exception may apply if you experience a life-threatening emergency).        

There are two types of TRICARE-authorized providers: network and non-network. The two stateside regional contractors (Humana Military and Health Net Federal Services, LLC) and overseas contractor (International SOS Government Services, Inc.) have established networks of providers. These TRICARE network providers accept payment from TRICARE as the full payment for any covered health care services you get, minus your required out-of-pocket costs, when applicable. They also file claims for you. If overseas, TRICARE network providers are only required to file claims for those in TRICARE Overseas Program (TOP) Prime and TOP Prime Remote, as well as active duty services members on leave or temporary duty. 

You may also see a non-network provider (also called out-of-network). These providers don’t have a signed agreement with the regional contractor. There are two types of non-network providers: participating and nonparticipating. A participating provider accepts payment from TRICARE as the full payment for any covered health care services you get, minus any out-of-pocket costs. They also file claims for you. If overseas, they may file claims for you. Nonparticipating providers provide neither of those services. If stateside, they may charge you up to 15 percent above the TRICARE-allowable chargeThe maximum amount TRICARE pays for each procedure or service.  This is tied by law to Medicare's allowable charges. for services. Outside the U.S. and U.S. territories, there may be no limit to the amount that nonparticipating providers may bill, and you’re responsible for paying any amount that exceeds the TRICARE-allowable charge. If you visit a nonparticipating provider, you may have to pay the provider first and file a claim for reimbursement later.

If you’re enrolled in a TRICARE Prime option, your primary care manager and specialty care providers will likely be a military hospital or clinic, or a civilian network provider. To see civilian specialists or non-network providers, you’ll need prior authorization from your regional contractor or you’ll pay more out of pocket under the point-of-service option. With TRICARE Select, you manage your own health care and may get care from any TRICARE-authorized providerAn authorized provider is any individual, institution/organization, or supplier that is licensed by a state, accredited by national organization, or meets other standards of the medical community, and is certified to provide benefits under TRICARE. There are two types of TRICARE-authorized providers: Network and Non-Network. you choose without a referral. You still may need prior authorization for some services. Your out-of-pocket costs vary based on the type of provider you see.

When you seek care, you have choices. Knowing which type of provider is best suited for the type of care you need and your coverage will help you save money. It will also allow you to take advantage of your full benefit.

Visit www.tricare.mil to learn more about your plan, costs and coverage. You can also view stateside and overseas provider directories.

Last Updated 7/31/2018