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