What is a network provider with TRICARE?
A network provider is a participating “civilian”(not on the base or a military employee) provider who has completed the TRICARE credentialing process and signed an insurance contract with the TRICARE administrator for your region.
Once this contract is signed and loaded, a network provider will be loaded into the provider directory on TRICARE’s website. Becoming a network provider means that you’ve accepted the terms of a contract and agreed to a reduced fee CMAC fee schedule (in most cases).
What is a non-network provider with TRICARE?
A non-network provider is a community provider or organization that is authorized to provide care to TRICARE beneficiaries but is not actually contracted with the TRICARE administrator in your region.
Non-network providers are called authorized or certified in many cases and have met all of the licensing and certification requirements of TRICARE. As a non-network or certified provider, there are yet two more distinctions that are important to consider. These two types of providers, are participating and non-participating. You cannot see TRICARE members unless you at least complete the initial credentialing paperwork and TRICARE verifies that you meet all of their credentialing standards. Once you’ve completed the initial credentialing, you then have a decision to make in regards to participating or not participating.
What is a Non-participating Provider with TRICARE?
It is an authorized hospital, institutional provider, physician, or other medical provider that provides medical services to TRICARE members but did not sign an agreement and therefore does not accept assignment.
By not accepting assignment, this non-participating provider can balance bill TRICARE members for up to 115% of the TRICARE (CMAC) fee schedule. TRICARE will still pay some of the claim but the remaining balance will be the patient’s responsibility. Typically, it’s best to be a non-participating provider in a region that is underserved.
What is a TRICARE Participating Provider:
Providers that participate (sign a contract) with TRICARE accept assignment from Tricare and agree to file claims to TRICARE for their members and accept payment from Tricare. They agree to accept the TRICARE allowable(which is determined by your contract) as payment in full (no balance billing).
Non-network individual providers or organizations that have not signed an agreement may still “participate” on a case-by-case basis but will be required to obtain an out of network authorization prior to providing service. Providers and organizations must obtain applicable copayments from TRICARE members and the applicable cost-shares/deductibles based on the member’s plan. An interesting fact is that hospitals which participate in Medicare by law, must also participate in TRICARE for inpatient services. For outpatient care, hospitals can elect to participate or not participate.