Are you looking for a new doctor? Finding the right doctor is important to your overall health. Regular checkups are one of the best ways to check for diseases and prevent future health problems. When searching for a doctor, you may find the terms “network provider” or “non-network provider.” Understanding these two types of provider is important to you and your family.
“Before seeking care with a civilian doctor, it is important that you know whether the provider is in the Tricare network or out-of-network,” said Mr. Paul Wuerdemann, Tricare health plan provider network lead at the Defense Health Agency. “There are some key differences between the two that may determine the type of provider you want to look at.”
Both types of providers must be authorized by TRICARE. Depending on your health plan and the type of care you get, you may have the option of visiting either type of provider. How much would 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 set forth in Tricare Choice in the United States Handbook, This means that they are part of the network of providers that participate in the TRICARE program. They have 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 take care of you at a fixed rate.
- They accept your in-network copay or cost-share as payment in full.
- They file a claim with Tricare for any outstanding balance due.
The same usually applies overseas. Overseas network providers also have an agreement with the TRICARE overseas contractor. However, the network providers agree to provide cashless and claimless services only to those who have Tricare Prime Overseas or Tricare Prime Remote Overseas. This means that if you are enrolled in these health plans, you will not have to pay upfront to receive services or file claims on your own.
A non-network provider is one who is authorized to provide care to Tricare beneficiaries but has not signed an agreement with Tricare. For non-network providers, keep the following in mind:
- They do not have a formal agreement with your Tricare contractor.
- They have the option of filing a claim with Tricare for you.
- They may require advance payment from you.
- There are two types of non-network providers:
- Participating Providers: These providers may file claims for you, accept payment directly from Tricare, and accept Tricare-acceptable fees as full payment for covered health care services (this includes your -out-of-network co-pay or cost-share).
- Non-Participating Providers: These providers have not agreed to accept Tricare-acceptable charges or file claims for you. You should expect to pay the first provider and file a claim with Tricare for reimbursement.
If in state, these providers may charge you 15% more than the Tricare-acceptable fee for services. You are responsible for paying your applicable inpatient costs, plus up to 15% of the TRICARE-allowable fee. If abroad Tricare Overseas Program Handbook, You are responsible for paying any amount that exceeds the Tricare-allowed fee.
Remember, if you see a provider who is not a Tricare-authorized provider, you will 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 learn how to become a Tricare provider.
Tricare for Life Providers
Do you have Tricare for Life (TfL) coverage? Your provider options vary with TfL. You can get care from participating Medicare, non-participating Medicare, or opt-out providers. There are important differences between Medicare providers that you should know about before receiving care. Explore your options by visiting 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 through all of the provider directories. You can also visit your Tricare contractor’s website to find their online provider directory:
In the Philippines, you need to see a preferred provider or 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’re not sure of the type of provider, remember to ask before seeking care to avoid surprise costs and more. Learn more about your health plan, costs and providers.
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