(TRICARE) SIMPLIFYING DEFINITIONS

From JBONJO@aol.com

This all gets so technical - and thus potentially confusing - and it is so easy for our Tricare dependent folks to panic when they get a billing turndown. Perhaps the following definitions may help clarify this:

A Tricare participating provider is either
1. A contracted network provider under Tricare Extra or Tricare Prime; or
2. A non-contracted provider who signs the Participation Agreement on the Tricare claim form DD-2642.

In either case, a participating provider always accepts assignment. Participation under Tricare automatically results in a legally enforceable agreement by the provider to accept the amount Tricare allows on the claim as full payment for all Tricare-covered services on that claim.

On a participating claim, Tricare sends its payment directly to the provider. The patient is responsible for paying the provider what Tricare does not pay, up to, but not more than the amount Tricare allowed on the claim.

The patient may not be charged more, i.e., he is not legally indebted for more, than the amount allowed for covered services on any claim on which the provider has signed the Participation Agreement, or if the provider is a Tricare Extra or Prime network provider.

The patient is responsible for paying the amount billed for any medical service Tricare denies ($0.00 allowed for that service). The patient should immediately file a written appeal with Tricare for any charge that is denied.

If the provider opts not to participate, he will not sign the Participation Agreement on the Tricare claim form. Tricare will send its payment directly to the patient. The patient is responsible for paying the provider up to, but not more than 115% of the amount Tricare allowed on the claim. The patient may not be charged more.

Google is not the place to search for Tricare providers or Tricare information. That's like looking for a brain surgeon in the Yellow Pages. The Office of the Assistant Secretary of Defense for Health Affairs (OASDHA) maintains an official Tricare Web site on the Internet at http://www.tricare.osd.mil.

Go to that site, click on your Tricare region on the Home Page Map, then search for Participating Provider on the page that comes up.