Military Health System

We have been notified that you are in breach of the participation agreement. (Name of Patient) advised us that (He/She) has been billed for amounts in excess of (His/Her) cost-share for services provided on (Dates), which is a violation of your participation agreement.

Please be advised that by signing the TRICARE claim form and indicating your willingness to accept assignment for these services, you agreed to accept the TRICARE, determined allowable charge for medical services/supplies listed on the claim form as payment in full. This is true even if you requested the beneficiary to complete a form agreeing to pay the full amount not paid by other health coverage or insurance plans.

Under TRICARE, authorized professional providers and institutional providers, other than certain hospitals, have the option of participating on a claim-by-claim basis. Participation is required for inpatient claims only for hospitals which are Medicare-participating providers. Hospitals which are not Medicare-participating but which are subject to the TRICARE DRG-based payment system must sign agreements to participate on all TRICARE inpatient claims in order to be authorized providers under TRICARE. All other hospitals may elect to participate on a claim-by-claim basis. Participating providers must indicate participation by signing the appropriate space on the applicable TRICARE claims form and submitting it to the appropriate TRICARE contractor. In the case of an institution or medical supplier, the claim must be signed by an official having such authority. This signature certifies that the provider has agreed to accept the amount paid by TRICARE or the TRICARE payment combined with the cost-sharing amount paid by or on behalf of the beneficiary as full payment for the covered medical services or supplies. Therefore, when costs or charges are submitted on a participating basis, the patient is not obligated to pay any amounts disallowed as being over the TRICARE-determined allowable cost or charge for authorized medical services or supplies.

A breach of the participation agreement which results in the patient being billed in excess of the allowable amount is specifically listed in the 32 CFR 199.9 as a fraudulent act. Your failure to honor the participation agreement is considered to be a serious infraction of TRICARE rules and regulations which could have repercussions with your TRICARE-authorized provider status as well as that of other Government agencies, such as Medicare and Medicaid.

To preclude any adverse action against your authorized provider status, please notify (Name of Patient) in writing that all attempts to collect amounts in excess of (His/Her) deductible and cost-share have ceased.

The total billed amount is (Amount) and the correct TRICARE allowable is (Allowable Amount). (Name of Patient) cost-share amount is (Appropriate Percentage), of (Put In Dollar Amount). The total payment amount to you is (Government's Cost-Share Plus Patient's Deductible and Cost-Share Amount). (Name of Patient) is only responsible for (His/Her) cost-share amount (Amount). Any amounts billed to the patient in excess the patient’s cost-share and deducible amount (Deductible Amount, if any), is a violation of your participation agreement.

Please provide to us a copy of your letter to (Name of Patient) within 15 days of the date of this letter. Please contact me in writing if you have any questions regarding this matter.