Tricare is amazing insurance but, just like any other insurance, you have to play within the rules. One thing that has always been confusing to me is the relationship between each type of Tricare provider. In-network, out-of-network, and non-participating providers – what does this mean? Like, why are there three groups? How do I know which one is which? How much will I pay if I go to each one?
With the help of some smart friends and readers, I think I’ve *finally* sorted it out. So let’s look at each type of provider and how they fit into your Tricare plan. Then we’ll review what questions to ask a provider to understand what type of relationship they have with Tricare.
Let’s start by making sure we understand how Tricare works in general. This part is important. Also, you need to understand that Tricare defines a provider as any person, business, or institution that provides healthcare or healthcare supplies. So your doctor is a provider, but their practice may also be a provider. The hospital is a provider. So is the company that provides a breast pump or CPAP supplies.
Then we can look at these three, nesting levels of Tricare providers:
- authorized vs. not authorized
- network vs. non-network
- participating vs. non-participating
Tricare only pays for care provided by authorized providers. To be authorized, a provider must fulfill the requirements of the Tricare program AND must have their authorization and certification verified by the regional Tricare contractor.
Not Authorized Providers
Providers who have not taken the steps to have their credentials verified and certified by the regional Tricare contractor are considered not authorized. Tricare will not pay for care from not authorized providers.
You can ask a provider to become Tricare-authorized. In theory, it is not hard. In reality, I’ve heard different stories.
Authorized Network Providers
Network providers are Tricare-authorized providers who have a written agreement with the Tricare contractor (Humana or Tricare West). They have agreed to accept Tricare’s negotiated amount as payment in full for their services. They may accept any anticipated copay or cost-share prior to the services being rendered. Network providers will file the claim with Tricare on your behalf, and they’ll accept the payment directly from Tricare.
When you use a network provider, you will only ever pay your co-payment or cost-share, and that amount will count towards your catastrophic cap. Your co-payment or cost-share may be less or more than the percentage that would be charged for a non-network provider. (Surprising fact: non-network providers can be cheaper than network providers, in some situations.)
Authorized Non-network Providers
Non-network providers are Tricare-authorized providers who do not have a written agreement with your regional Tricare contractor. Within the group of non-network providers, there are two smaller groups: participating non-network providers, and non-participating non-network providers. It’s a little tricky because non-network providers don’t have to pick being just participating or non-participating. They can decide on a claim-by-claim basis. So this may require some conversation about whether they will be acting as a participating provider for your specific care.
Non-network providers may be less expensive than network providers in some situations. This is because network providers have a flat co-payment, and non-network providers have a percentage rate that you’re responsible to pay. The cost for a non-network provider being lower happens less often if the provider is non-participating and charges up to 15% more than the Tricare-authorized amount.
Authorized Participating Non-network Providers
Participating non-network providers function pretty similarly to network providers. They agree to accept Tricare’s negotiated charges as payment in full for care, file claims on behalf of the beneficiary, and accept payment directly from Tricare.
By federal law, hospitals that participate in Medicare must also participate in TRICARE for inpatient care, but there is no such rule for outpatient care.
Because you pay a percentage when you see non-network providers, non-network providers may be less expensive than network providers in some situations.
Authorized Non-participating Non-network Providers
Non-participating providers do not agree to file claims for the clients, nor do they agree to accept payments directly from Tricare. The beneficiary must pay their bill with a non-participating provider directly, sometimes in advance of treatment. Then, the beneficiary files a claim with Tricare.
Non-participating providers may charge up to 15% more than Tricare-allowable charges. This excess is the responsibility of the beneficiary.
Questions To Ask A New Provider
As you can see, it is a little confusing. When you call a new provider, be sure to ask all the questions to be sure you understand the relationship between the provider and Tricare. This order is probably the most efficient:
Are you a Tricare network provider? Asking this question first can eliminate all the other questions because if the answer is yes, you know that they are also authorized, and participating vs. non-participating does not apply.
If the answer to the first question is no, then ask: Are you a Tricare-authorized provider? The provider needs to be authorized for Tricare to pay for care.
Once you’ve established that they are not a network provider, but they are Tricare-authorized, then there are two questions: Are you a participating non-network provider? Then, depending on how that question is answered, you’ll want to ask: Are there any treatments or circumstances in which you would be (participating/non-participating, as appropriate)?
Because I’m uptight about stuff, I want to get this in writing, like an email. That may not always be possible, but you sure can try.
I also ask every time you visit. When they ask if there have been any changes to your health insurance, you can casually say, “And have there been any changes to your relationship with Tricare?” Maybe it’ll get to be a good joke between the receptionist and you 🙂
If this isn’t clear enough, or you have any additional questions, please comment!
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