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TRICARE Policy Manual 6010.60-M, April 1, 2015
Providers
Chapter 11
Section 1.2
Institutional Provider, Individual Provider, And Other Non-Institutional Provider Participation
Issue Date:  
Authority:  32 CFR 199.6; 10 USC 1079(j)
Revision:  
1.0  DESCRIPTION
Institutional providers (United States Code (USC), Section 1079(j) of Title 10), in order to be authorized providers under TRICARE must be participating providers. Individual and other non-institutional providers, that are not participating providers, may elect to participate on a claim basis. All individual and other non-institutional providers either operating in or outside an institutional provider who are nonparticipating providers are subject to the TRICARE balance-billing limit.
2.0  BACKGROUND
Per 32 CFR 199.6(b), institutional providers must participate on all claims. In most cases (except for providers under Diagnosis Related Groups (DRGs), Outpatient Prospective Payment System (OPPS), and the inpatient mental health per diem payment system), a participation agreement is required. By definition, participating providers whether institutional providers, individual providers, or other non-institutional providers, agree to accept the TRICARE payment as full payment for the care services or supplies. Individual providers and other non-institutional providers that are not participating providers are limited to the amount they can collect from the beneficiary.
3.0  POLICY
3.1  All institutional providers must participate under TRICARE to be authorized providers. Participation agreements are required unless the provider comes under the TRICARE DRG, TRICARE OPPS, or inpatient mental health reimbursement systems. TRICARE payments to institutional providers are complete payments. No additional payments shall be billed to the beneficiary except for any required beneficiary deductible and copayment amounts.
3.2  Individual providers including providers salaried or under contract by an institutional provider, e.g., hospital, and other non-institutional providers, e.g., Ambulatory Surgical Centers (ACSs), independent laboratories, suppliers of portable x-ray services, ambulance companies, medical equipment firms and medical supply firms, and mammography suppliers, etc. who are not participating providers may not balance bill a beneficiary an amount that exceeds the applicable balance billing limit. This means that the individual provider or non-institutional provider is required to accept the lower of the billed charge or 115% of the TRICARE allowable amount. No additional payments shall be billed to the beneficiary except for any required beneficiary deductible and copayment amounts.
3.3  All network providers must be Medicare participating providers. For the purposes of TRICARE, “Medicare participating” is interpreted to mean participation on a claim-by-claim basis. Participation on a claim-by-claim basis means that while network providers must agree to participate with Medicare on all claims that involve a TRICARE beneficiary (dual-eligible claims), they are not required to enter into a participation agreement with Medicare (individual and other non-institutional providers are NOT required to sign a Centers for Medicare and Medicaid Services (CMS) 460 Form) as a prerequisite to joining a TRICARE network. The requirement for Medicare participation applies only to providers that are recognized under Medicare and are eligible to participate with Medicare. This does not mean that a TRICARE-authorized provider not recognized under Medicare is exempt from joining a TRICARE network; it simply means that such a provider is exempt from the Medicare participation requirement.
4.0  EFFECTIVE DATE
August 1, 2003.
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