Tricare Help: Sorting out Tricare ‘providers’ - Getting out, military health issues - Navy Times

Tricare Help: Sorting out Tricare ‘providers’

Answering your questions on Tricare.

Q. What is the difference between an authorized provider and a participating provider?

All health care insurers require some form of provider registration. To be paid for services rendered to Tricare beneficiaries, providers must supply Tricare with proof that they are qualified and properly licensed to render certain services.

When that’s done, Tricare will issue a provider identification number, which must accompany all claims. That person or organization is then a Tricare-authorized provider.

Tricare will not pay for any services received from an unauthorized provider.

An authorized provider who participates in Tricare will sign a legally binding agreement to accept the amount Tricare allows as full payment for all services submitted with a given claim.

When Tricare pays its share to the provider and the patient pays his share, the claim and all the associated charges are paid in full. The patient may not be charged more than Tricare allows on that claim.

If the authorized provider chooses not to participate on a claim, federal law allows the patient to be charged up to 15 percent more than the amount Tricare allows for the services on that claim.

Tricare pays no part of this surcharge. The patient is responsible for it, along with the normal 20 percent to 25 percent cost share.

Participation in Tricare is voluntary on a claim-by-claim basis.

Providers who see Medicare patients will recognize the 15 percent surcharge as the “Limiting Charge” provision of Medicare law. Congress made this apply to Tricare claims in 1983.

Q. I am a retired federal employee with the federal Blue Cross Blue Shield plan. Can I use Tricare to pay what the other plan does not pay?

To file with Tricare as last payer to other health insurance, complete a Tricare Claim Form DD 2642. Download the form and find the address for filing claims online.

Attach a copy of the bills that were sent to the other plan and a copy of its explanation of benefits reporting its processing of all charges. Mail the package to Tricare.

Tricare will pay most, if not all, of what the other plan did not. Usually, that will cover your other plan’s deductibles and co-payments.

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Write to Tricare Help, Times News Service, 6883 Commercial Drive, Springfield, VA 22159; or tricarehelp@militarytimes.com. In e-mail, include the word “Tricare” in the subject line and do not attach files. Get Tricare advice any time at our blog.