Difference between network and non-network provider, participating and not participating.

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

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