FALLS CHURCH, Virginia –
Are you looking for a new doctor? Finding the right doctor is crucial to your overall health. Regular checkups are one of the best ways to screen for diseases and prevent future health problems. When searching for a doctor, you may come across the term “network provider” or “non-network provider.” Understanding these two provider types matters to you and your family.
“Before seeking care with a civilian doctor, it’s important you know if the provider is in the TRICARE network or out of the network,” said Mr. Paul Wuerdeman, TRICARE Health Plan provider networks lead with the Defense Health Agency. “There are some important differences between the two that could determine the type of provider you want to see.”
Both types of providers must be authorized by TRICARE. Depending on your health plan and the type of care you need, you may have the option of visiting either provider type. How much will you pay? How do you know which one is best for you? Let’s take a look at the differences between network and non-network providers.
A network provider is authorized and has signed an agreement with TRICARE, as outlined in the TRICARE Choices in the United States Handbook. This means they’re a part of the network of providers who participate in the TRICARE program. They’ve agreed to follow TRICARE’s policies and procedures. With network providers, keep the following in mind:
- They have a formal agreement with your TRICARE contractor.
- They agree to provide care to you at a negotiated rate.
- They accept your in-network copayment or cost-share as payment in full.
- They file claims with TRICARE for any remaining amount due.
The same generally applies overseas. Network providers overseas also have an agreement with the TRICARE overseas contractor. However, network providers only agree to provide cashless and claimless services to those who have TRICARE Prime Overseas or TRICARE Prime Remote Overseas. This means you won’t have to pay upfront to get services or file your own claims if you’re enrolled in these health plans.
A non-network provider is one who is authorized to provide care to TRICARE beneficiaries but hasn’t signed an agreement with TRICARE. For non-network providers, keep the following in mind:
- They have no formal agreement with your TRICARE contractor.
- They have the option to file claims with TRICARE for you.
- They might require payment from you upfront.
- There are two types of non-network providers:
- Participating providers: These providers may file claims for you, accept payment directly from TRICARE, and accept the TRICARE-allowable charge as payment in full for covered health care services(this includes your out-of-network copayment or cost-share).
- Nonparticipating providers: These providers haven’t agreed to accept the TRICARE-allowable charge or file claims for you. You should expect to pay the provider first and file a claim with TRICARE for reimbursement.
If stateside, these providers may charge you up to 15% more than the TRICARE-allowable charge for services. You’re responsible for paying your applicable patient costs, plus up to 15% of the TRICARE-allowable charge. If overseas, TRICARE Overseas Program Handbook. You’re responsible for paying any amount that exceeds the TRICARE-allowable charge.
Remember, if you see a provider who isn’t a TRICARE-authorized provider, you’ll be responsible for the full cost of your care. If you know a provider who would like to become a TRICARE-authorized provider, encourage them to check out how to become a TRICARE provider.
TRICARE For Life providers
Do you have TRICARE For Life (TFL) coverage? Your provider options differ with TFL. You can get care from Medicare participating, Medicare non-participating, or opt-out providers. There are key differences between Medicare providers to know as well before you get care. Explore your options by going to the Medicare Provider Directory.
How to find a provider
When you need to find a provider, you can use the Find a Doctor tool or go to All Provider Directories. You can also visit your TRICARE contractor’s website to search their online provider directory:
In the Philippines, you need to see a preferred provider or a certified provider. Use the Philippine Provider Search Tool to locate a provider near you.
Remember that some services from your provider may require a referral or pre-authorization depending on your health plan. Also, if you aren’t sure about the provider type, remember to ask before you get care to avoid surprise costs and more. Learn more about your health plan, costs, and providers.
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