What is a network provider with TRICARE?
A network provider is a TRICARE-authorized civilian provider that has signed a network contract with the regional contractor.
Network providers agree to the negotiated payment terms and file claims for TRICARE patients. Confirm the contract’s effective date and directory listing with the regional contractor before describing your practice as in-network.
What is a non-network provider with TRICARE?
A non-network provider is authorized to care for TRICARE beneficiaries but has not joined the regional contractor’s network.
Non-network providers must meet TRICARE’s authorization requirements. Within this category, providers may be participating or nonparticipating. Ask the regional contractor which certification or enrollment steps apply to your provider type before billing TRICARE.
What is a nonparticipating provider with TRICARE?
A nonparticipating provider is an authorized non-network provider that does not accept assignment for the service. Network status and participation on a claim are separate distinctions.
In the United States, a nonparticipating provider may charge up to 15% above the TRICARE-allowable charge. That additional amount is separate from the patient’s deductible and cost-share. Patients may need to pay upfront and file a claim themselves. Overseas rules differ; check the applicable regional guidance.
What is a TRICARE participating provider?
A participating provider accepts assignment and the TRICARE-allowable charge for the service. The patient remains responsible for the applicable deductible and cost-share. A non-network provider can participate on a case-by-case basis without joining the network.
Whether a referral or pre-authorization is needed depends on the patient’s plan, status, and service. Non-network participation does not remove those requirements. Confirm coverage and required approvals before providing care.
Sources: TRICARE network providers, non-network providers, cost terms, and getting care and authorization requirements.
For fee-schedule resources, visit our TRICARE CMAC tools page. For help with payer applications, explore PPS credentialing and enrollment support.