TRICARE Provider Types
TRICARE defines a provider as a person, business, or institution that provides or gives health care. For example, doctors are individual providers, hospitals are institutional providers, and ambulance companies are corporate providers. There are many other provider types. A provider must be authorized under TRICARE regulations and certified by TriWest. On the following page provides
an overview of TRICARE provider types.
TRICARE-Authorized Providers
• TRICARE-authorized providers meet state licensing and certification requirements and are certified by TRICARE to provide care to TRICARE beneficiaries. TRICARE-authorized providers include doctors, hospitals, ancillary providers (laboratory and radiology providers), and pharmacies. Beneficiaries are
responsible for the full cost of care if they see providers who are not TRICARE-authorized.
• There are two types of TRICARE-authorized providers: Network and Non-network.
Network Providers
• Regional contractors have established networks, even in areas far from
military treatment facilities.
• TRICARE network providers:
• Have signed agreements with TriWest Healthcare Alliance Corp. (TriWest) to provide care
• Agree to file claims and handle other paperwork for TRICARE beneficiaries
Non-Network Providers
• Non-network providers do not have signed agreements with TriWest
and are, therefore, considered “out of network.”
• There are two types of non-network providers: Participating and
Nonparticipating.
Participating
• May choose to participate on a claim-by-claim basis
• Agree to file claims for TRICARE beneficiaries, accept payment directly from TRICARE, and accept the TRICARE-allowable charge as payment in full for
their services
Nonparticipating
• Do not agree to accept the TRICARE-allowable charge or file claims for TRICARE beneficiaries
• Have the legal right to charge beneficiaries up to 15% above the TRICARE-allowable charge for services
