The analysis of any legal or medical billing is dependent on numerous specific facts — including the factual situations present related to the patients, the practice, the professionals and the medical services and advice. Additionally, laws and regulations and insurance and payer policies are subject to change. The information that has been accurate previously can be particularly dependent on changes in time or circumstances. The information contained in this web site is intended as general information only. It is not intended to serve as medical, health, legal or financial advice or as a substitute for professional advice of a medical coding professional, healthcare consultant, physician or medical professional, legal counsel, accountant or financial advisor. If you have a question about a specific matter, you should contact a professional advisor directly. CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
Tricare Provider Enrollment
Tricare only reimburses authorized providers. Tricare-authorized providers must meet Tricare licensing and certification standards. This means providers must be licensed in their respective states and not banned from participation in federal healthcare programs.
Certified providers are considered non-network Tricare-authorized providers unless they choose to join the Tricare network. Non-network providers may also choose to accept assignment (that is, participate) on a case-by-case basis.
Tricare West: Certification Applications
Tricare East: Certification Applications
Network providers sign an agreement with the applicable Tricare contractor (East or West). Network providers agree to file claims and handle paperwork for Tricare beneficiaries and agree to accept the Tricare allowable charges as payment in full for services. Network providers must also carry malpractice insurance.
Non-network providers do not sign an agreement with the applicable contractor, they can be participating or non-participating.
May choose to participate on a claim-by-claim basis, agree to accept payment directly from Tricare and accept the Tricare allowable charge as payment in full for their services.
Non-participating providers do not agree to accept Tricare allowable charges or file claims on behalf of beneficiaries. Non-participating providers the legal right to charge beneficiaries up to fifteen (15%) percent above the Tricare allowable charge for services.
Note: When a Tricare Prime beneficiary is referred to a nonparticipating, non-network provider, the beneficiary is only responsible for applicable copayments/cost-shares, but not for any balance billing amount.
Tricare Provider Manuals
TRICARE Policy Manual 6010.60-M Ch. 11 § 1.2
Therapy Comply is a healthcare compliance firm that seeks to bring high quality web-based compliance guidance and one-on-one consulting services to small and medium size physical, occupational, and speech therapy practices.
Join today as either a monthly or a yearly member and enjoy full access to the site and a significant discount to our live and recorded webinars. Members also have access to compliance and billing support.