3.0 POLICY
3.1 No
Obligation to Pay
PPOs provide
services at a discounted rate through contractual arrangements with
a third-party payer. In some cases either the PPO or the beneficiary
may bill TRICARE for the difference between the provider’s normal
charge and the contractually-set discount amount. TRICARE cannot
pay even on a secondary payer basis for these amounts. The rationale
for this is that the contracts which PPOs have with third-party
payers normally provide that they will be paid in full by the third-party
payer, taking any discounts into consideration. Since this would
leave no remaining amounts as the responsibility of the beneficiary,
there is no further legal obligation to pay.
3.2 Secondary Payer
Payments can be made on a secondary
payer basis in those situations where the person submitting the claim--either
the beneficiary, the individual provider, or the PPO--submits evidence
of beneficiary liability beyond the amounts paid to the PPO by the
primary payor.
3.3 Payment
for Non-PPO Members
PPO providers
may be authorized providers in their own right and may render services
to individuals who are not PPO members, and these services may be
reimbursed.