Who You See for Care Matters: TRICARE Provider Types

3/29/2019

When you need care, you can visit several types of providers. Depending on where your provider is located, you may seek care at a military hospital or clinic or from your TRICARE-authorized provider.

When seeking care outside a military hospital or clinic, your ability to choose a provider may depend on your TRICARE plan, whether you need a referral, and the type of care you need. Seeing TRICARE-authorized providers saves you money and ensures quality treatment. There are different types of TRICARE-authorized providers. The type you see can affect how much you pay and how you file claims.

TRICARE-authorized Providers

A provider must be TRICARE-authorized for TRICARE to pay any part of your claim. If you see a provider who isn’t TRICARE-authorized, you’re responsible for the full cost of care. The TRICARE regional contractors have established networks of providers. If stateside or overseas, use the Find a Doctor tool to find a TRICARE-authorized providerClick to closeAn 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.. The overseas provider search tool is another way to find a provider abroad. Search the preferred-provider network if you live in the Philippines. There are two types of TRICARE-authorized providers. They include network and non-network.

Network Providers           

Network providers have signed an agreement with your regional contractor to provide you care. They file claims for you and accept TRICARE payment as the full payment for covered health care services.

Sponsor status and location plays a role in determining what overseas options you may have. If overseas, TRICARE network providers have an agreement with the overseas contractor. They agree to provide cashless and claimless services to those in TRICARE Overseas Program (TOP) Prime and TOP Prime Remote. But these providers don’t have to file claims for those in TOP Select. Check with your TOP Regional Call Center before visiting a civilian provider.

Non-network Providers           

Non-network providers don’t have a signed agreement with your regional contractor. This makes them out of network, also known as non-network. There are two types of non-network providers. They include participating and nonparticipating.

Participating Providers

Among non-network providers, using a participating provider is your best option. These providers file claims for you and accept TRICARE payment as the full payment for any covered health care services.

Outside the U.S. and U.S. territories, participating non-network providers don’t have an agreement with the overseas contractor. They may provide cashless and claimless services to TOP Prime and TOP Remote beneficiaries. But they don’t have to submit claims on behalf of TOP Select beneficiaries.

Nonparticipating Providers           

Nonparticipating providers don’t file claims for you. They also don’t accept TRICARE payment as the full payment for covered services. Because of these reasons, you should expect to pay the provider first and file a claim with TRICARE to get money back. If stateside, these providers may charge you up to 15 percent above the TRICARE-allowable chargeClick to closeThe maximum amount TRICARE pays for each procedure or service.  This is tied by law to Medicare's allowable charges. for services. You’re responsible for paying this amount as well as applicable patient costs.

If you visit a nonparticipating non-network provider overseas, there may be no limit to the amount that a provider may bill you. You’re responsible for paying any amount that exceeds the TRICARE-allowable charge.

Understanding TRICARE provider types will help you get quality health care, save money, and take command of your health. To learn more about your provider options outside of your military hospital or clinic, visit Provider Types. To visit a provider in your area, search the provider directories.

Last Updated 4/26/2019