FALLS CHURCH, Va. –
You may have heard the terms “allowable charge” and “balance billing.” But what do these terms mean when you have TRICARE?
- The TRICARE-allowable charge is the maximum amount TRICARE will pay for a procedure, service, or equipment. TRICARE-allowable charges vary based on the provider and the type, place, and date of service. The TRICARE-allowable charge determines what you’ll pay for your TRICARE cost-share.
- Balance billing is when a provider bills you for the difference between what they charge for a service (often called the “billed amount” or “billed charges”) and the TRICARE-allowable charge for that service.
Is a provider allowed to bill you for this difference? It depends on what type of provider they are.
There are two types of TRICARE-authorized providers: network providers and non-network providers. There are also two types of non-network providers: participating providers and nonparticipating providers.
“Only nonparticipating providers are allowed to practice balance billing,” said Ashli Van De Weert, health systems specialist, TRICARE Health Plan, at the Defense Health Agency. “In the U.S. and U.S. territories, these providers can’t charge you more than 15% of the TRICARE-allowable charge.”
Keep reading to learn more about different types of TRICARE-authorized providers and what they’re allowed to charge you.
Network providers
A network provider is a TRICARE-authorized provider who has signed an agreement with your
regional contractor to follow TRICARE policies and procedures. This means they:
- Accept a negotiated rate as payment in full
- File claims so that you don’t have to
- Won’t ask you to sign any documents to make you pay amounts above your copayment or cost-share—if this happens, contact your regional contractor.
Non-network providers
Non-network providers are also TRICARE-authorized providers. These providers
haven’t signed a formal agreement with your regional contractor. Because of this, they may see TRICARE patients on a case-by-case basis.
Participating providers are non-network providers who accept the TRICARE-allowable charge as payment in full for covered health care services. This means that after you meet your deductible, you’ll only pay a cost-share when you visit the provider. In the U.S., these providers will file claims for you.
Nonparticipating providers are non-network providers who haven’t agreed to accept the TRICARE-allowable charge as payment in full for services. They also haven’t agreed to file claims for you.
What does this mean for you?
- When you see a nonparticipating provider, you may have to pay the full amount to the provider up front and file a claim with TRICARE for reimbursement. (TRICARE won’t reimburse you for deductibles, cost-shares, and charges above the TRICARE-allowable charge.)
- In the U.S., nonparticipating providers have the legal right to charge you up to 15% more than the TRICARE-allowable charge. (This doesn’t apply if you sign a statement agreeing to pay more than the allowable charge.) This is in addition to any deductibles or cost-shares you pay.
- Overseas, there may be no limit to how much a nonparticipating provider may bill you. You’re responsible for paying any amount that’s more than the TRICARE-allowable charge.
Tip: Before you see a non-network provider, call the provider to see if they participate in TRICARE.
Making sure you don’t overpay
It’s important to make sure your provider isn’t making you pay more than they’re allowed to. This means that you should check your TRICARE
explanation of benefits when you get a bill from a nonparticipating provider.
Your EOB will show you the provider’s billed amount (what they charge for the care). It will also show the TRICARE-allowable charge for the care you got, and the cost-share you paid. Your cost-share is the portion of the TRICARE-allowable charge that you’ll need to pay.
Here’s an example. A nonparticipating provider in the U.S. bills $1,000 for a service. The TRICARE-allowable charge for this service is $850. By law, the provider can ask you to pay $127.50 (15% of $850), in addition to your deductible and cost-share.
If you’re being billed for more than 15% of the allowable charge or if you’ve already paid more than this, you should call your regional contractor.
Tips for choosing a provider
Are you deciding whether to see a network or non-network provider? Keep these things in mind.
- Out-of-pocket costs: In general, you’ll pay less out of pocket when you see a network provider than you will if you see a non-network provider. Go to Health Plan Costs to compare network and non-network costs.
- Your plan’s rules: Different TRICARE plans have different rules for seeing non-network providers. If you don’t follow these rules, you may pay more out of pocket. Go to Non-Network Providers and Book Appointments to learn more.
- Your catastrophic cap: The catastrophic cap is the most you or your family may pay out of pocket for covered TRICARE health services each calendar year. It limits the amount of out-of-pocket expenses you pay for covered services, as noted in the TRICARE Costs and Fees Sheet. However, charges above the TRICARE-allowable charge don’t count toward your catastrophic cap.
Looking for more information about TRICARE costs? Check out Cost Terms.
Would you like the latest TRICARE news sent to you by email? Visit TRICARE Subscriptions to get benefit updates, news, and more.