Direct Answer
TRICARE is the health care program for uniformed services members, retirees, and their dependents, administered by the Defense Health Agency (DHA) and managed through regional contractors (Humana Military for East, Health Net for West). TRICARE billing requires understanding which TRICARE program the patient is enrolled in (TRICARE Prime, Select, For Life, Young Adult, Reserve Select, etc.), whether the provider is an authorized TRICARE network or non-network provider, and which regional contractor to bill. TRICARE uses Medicare-based fee schedules with adjustments and follows many Medicare billing rules, making it manageable for practices already familiar with Medicare billing.
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TRICARE Program Options
TRICARE has multiple program options with different enrollment requirements, cost-sharing structures, and provider access rules: TRICARE Prime: an HMO-style plan that requires enrollment; patients are assigned a primary care manager (PCM) at a military treatment facility (MTF) or in the civilian network; referrals are required to see specialists; TRICARE Prime is available to active duty service members and their families in areas with MTFs; TRICARE Select: a PPO-style plan with no enrollment required (automatic coverage); patients can see any TRICARE-authorized provider without a referral; cost-sharing is higher than Prime for non-network providers; Select is available to all eligible beneficiaries and is the most commonly used program among retirees in areas without MTFs; TRICARE For Life (TFL): secondary coverage for Medicare-eligible TRICARE beneficiaries (age 65+ retirees and their dependents); TRICARE pays after Medicare as the secondary payer; TFL has essentially no cost-sharing for Medicare-covered services that Medicare pays; TRICARE Young Adult (TYA): coverage for adult dependent children (age 21–26) of eligible service members; offered as a Prime or Select option; TRICARE Reserve Select (TRS): coverage for National Guard and Reserve members not on active duty; TRICARE-related coverage: CHAMPVA (Civilian Health and Medical Program of the Department of Veterans Affairs) covers dependents of veterans with 100% service-connected disabilities — it is not TRICARE but uses similar billing and processes. Knowing which program a patient is enrolled in is essential for billing — the program determines whether a referral is required, what the cost-sharing is, and which plan management contractor to bill.
Network vs. Non-Network Provider Billing
TRICARE provider status affects both reimbursement rates and patient cost-sharing: TRICARE network provider (authorized and contracted): the provider has signed a network agreement with the TRICARE regional contractor; payment is at the TRICARE Maximum Allowable Charge (TMAC), which is typically based on Medicare's fee schedule at comparable rates; claims are submitted directly to the regional contractor; the provider accepts assignment and cannot bill the patient more than the applicable cost-sharing (deductible, copay); TRICARE non-network provider (authorized but not contracted): any provider who holds an active state license and is not excluded from federal programs can be an authorized TRICARE provider even without a network contract; non-network providers may bill up to 15% above the TMAC; patients enrolled in TRICARE Select (not Prime) can see non-network authorized providers; non-network billing: the provider can bill the patient directly, and the patient submits the claim to TRICARE for reimbursement, OR the provider submits to TRICARE directly (provider filing the claim on the patient's behalf); non-network providers should not require Prime patients to pay upfront — TRICARE Prime patients must have a referral to see non-PCM providers, and network coverage applies. TRICARE-unauthorized providers: non-licensed or excluded providers; patients who see unauthorized providers are responsible for the entire cost of care. Active duty service members have special rules: active duty service members have no cost-sharing requirements; they must use network or MTF providers; billing for active duty service members requires verification of their specific coverage status and that the service was authorized.
Claim Submission and Regional Contractors
TRICARE claims are submitted to regional contractors based on the patient's residence: Humana Military (East Region): covers the eastern United States — Connecticut, Delaware, Florida, Georgia, Indiana, Kentucky, Maine, Maryland, Massachusetts, Michigan, Mississippi, New Hampshire, New Jersey, New York, North Carolina, Ohio, Pennsylvania, Rhode Island, South Carolina, Tennessee, Vermont, Virginia, West Virginia, and Washington DC; Health Net Federal Services (West Region): covers the western United States — Alaska, Arizona, California, Colorado, Hawaii, Idaho, Iowa, Kansas, Minnesota, Missouri, Montana, Nebraska, Nevada, New Mexico, North Dakota, Oklahoma, Oregon, South Dakota, Texas, Utah, Washington, Wisconsin, Wyoming. Note: TRICARE regional contractors change periodically — verify current contractor assignments as these have been renegotiated by DHA. Claim submission format: TRICARE accepts 837P for professional claims and 837I for institutional claims; claims can be submitted electronically through standard clearinghouses using the regional contractor's payer ID; paper claims are submitted on CMS-1500; electronic submission is strongly preferred and required for network providers. TRICARE timely filing: 1 year from the date of service for network providers; 365 days for non-network providers; for TRICARE For Life, there is a specific coordination period after Medicare adjudicates — TFL claims must be filed within 18 months of the date of service. TRICARE Explanation of Benefits (EOB): the EOB from TRICARE identifies the allowed amount, TRICARE payment, and patient cost-sharing (if any); coordination with Medicare for TFL patients results in two EOBs that must be reconciled.
Coverage Rules and Excluded Services
TRICARE coverage is defined in the TRICARE Policy Manual and largely mirrors Medicare coverage for medical services, with some notable differences: Services generally covered by TRICARE: all medically necessary services that are not specifically excluded; preventive care (immunizations, well-child care, preventive screenings); mental health services; substance use disorder treatment; pharmacy benefits through the TRICARE Pharmacy program; Services excluded from TRICARE coverage: cosmetic procedures (same standard as Medicare — unless reconstructive after injury or illness); dental care (except where specifically covered — TRICARE dental is a separate program, the TRICARE Dental Program); hearing aids (except in specific circumstances); eyeglasses and contact lenses (except after cataract surgery); services available at a military treatment facility (MTF): if the service is available at an MTF near the patient's home, TRICARE may deny payment for civilian care; this is the "space-available" rule — active duty and Prime beneficiaries are expected to use MTF resources first when available; TRICARE prior authorization: TRICARE requires PA for certain services — the PA list is program-specific (Prime requires PA through the PCM; Select has fewer PA requirements); PA requirements are published in the TRICARE Policy Manual and the regional contractor's provider manual; outpatient mental health care, specialty referrals from Prime PCMs, certain surgical procedures, and high-cost drugs typically require PA; Referral requirements for Prime: TRICARE Prime is an HMO — specialty care requires a referral from the PCM; billing a TRICARE Prime patient for specialty care without a valid referral results in a denial and the provider may not be able to collect from the patient.
Behavioral Health and Mental Health Billing
TRICARE has robust mental health and substance use disorder (SUD) benefits that are important for the military and veteran population: TRICARE mental health coverage: outpatient mental health services do not require a referral for TRICARE Select (non-Prime) beneficiaries; TRICARE Prime beneficiaries require a referral for specialty mental health care beyond the PCM's scope; TRICARE covers individual psychotherapy (90832, 90834, 90837), group therapy (90853), psychiatric evaluation (90791, 90792), and medication management E&M; TRICARE behavioral health coverage is not subject to the same session limits or visit limits that historically applied to commercial plans — MHPAEA parity requirements apply to TRICARE Select; Residential treatment: TRICARE covers residential mental health treatment (inpatient psychiatric, residential SUD treatment) with authorization; billing uses the standard inpatient revenue codes and HCPCS/CPT codes for the treatment facility; EMDR (Eye Movement Desensitization and Reprocessing) for PTSD: TRICARE covers EMDR for PTSD — important for the military population where PTSD prevalence is high; CPT 90849 or the psychotherapy codes apply; TRICARE Network Extended Care Health Option (ECHO): for beneficiaries with qualifying special needs — covers additional services not in the standard TRICARE benefit; ECHO billing uses special benefit codes and requires ECHO eligibility confirmation before billing. Mental health parity under TRICARE: TRICARE Select is subject to MHPAEA parity requirements; treatment limitations for mental health and SUD services must be no more restrictive than for comparable medical/surgical services.
FAQ
Does TRICARE follow the same billing rules as Medicare?
TRICARE billing rules are largely based on Medicare billing rules but with important TRICARE-specific differences. Areas where TRICARE follows Medicare rules: CPT and HCPCS code selection — TRICARE uses the same code sets as Medicare; fee schedule basis — TRICARE Maximum Allowable Charges (TMAC) are derived from the Medicare Physician Fee Schedule for most professional services; claim format — CMS-1500 for professional claims, UB-04 for institutional claims; many Medicare coverage policies — TRICARE generally follows Medicare Local Coverage Determinations and National Coverage Determinations for medical services. Areas where TRICARE differs from Medicare: eligibility age — TRICARE covers non-elderly beneficiaries (active duty, dependents, working-age retirees), while Medicare is primarily for patients 65+; TRICARE For Life is secondary to Medicare for dual-eligible beneficiaries, rather than primary; Program structure — TRICARE has multiple program options (Prime, Select, TFL, etc.) with different referral and cost-sharing requirements, unlike Medicare which has two programs (Traditional and Medicare Advantage); Mental health coverage — TRICARE's mental health coverage rules differ from Medicare's in important ways; TRICARE does not have the same homebound requirement for home health benefits; Authorization requirements — TRICARE Prime's PCM referral requirement is more restrictive than traditional Medicare's absence of referral requirements; Fee schedule modifiers — some TRICARE modifier rules differ from Medicare; always verify TRICARE-specific modifier guidance in the regional contractor's provider manual rather than assuming Medicare modifier rules apply without verification.
How does TRICARE For Life work as secondary coverage, and how should claims be submitted?
TRICARE For Life (TFL) is secondary coverage for Medicare-eligible TRICARE beneficiaries — primarily military retirees over age 65 and their Medicare-eligible dependents. TFL essentially makes the beneficiary's out-of-pocket cost zero for Medicare-covered services at network providers, because: Medicare pays primary; TRICARE For Life pays secondary (covering Medicare Part A and B deductibles and cost-sharing); the beneficiary pays nothing (no copay, no deductible) for Medicare-covered services at participating providers. TFL claim submission: for electronic claims: Medicare and TRICARE have a crossover claim arrangement — when the provider bills Medicare electronically through the standard Medicare MAC, the claim is automatically forwarded to TRICARE For Life after Medicare adjudicates (crossover); no separate TRICARE claim filing is required when the crossover works correctly; for manual/paper claims or when the crossover fails: the provider submits the Medicare EOB along with the TRICARE claim to Wisconsin Physicians Service (WPS) — the national TFL claims processor (note: verify current TFL contractor, as these can change); Timely filing for TFL crossover: TFL has an 18-month timely filing window from the date of service; billing errors: the most common TFL billing error is filing directly with TRICARE For Life before billing Medicare — always bill Medicare first; a TFL claim without a Medicare EOB is typically denied; for Medicare non-covered services, the TFL benefit for those services may differ — TFL does not automatically cover services Medicare denies as non-covered; Patient cost-sharing: TFL beneficiaries have essentially no out-of-pocket cost for Medicare-covered services at network providers; balance billing is prohibited for TFL patients at Medicare-participating providers (same standard as Medicare); non-network non-TRICARE-participating providers who do not accept assignment can balance bill the difference between their charge and the TMAC — but this is uncommon and controversial.
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