Military Health System

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.