Understanding Balance Billing to Save Money, Stress

As a TRICARE beneficiary, you are able to see different doctors. What you may not see is the type of agreement between the provider and TRICARE. The type of provider you see may affect your health care costs, so you should  know the difference.

Different Provider Types

To become part of TriWest’s network, a provider must sign a contract with TriWest, agreeing to serve TRICARE beneficiaries and to accept the negotiated rate or TRICARE maximum allowable charge (TMAC) as payment in full for his or her services.

Non-network providers have not signed a contract with TriWest. However, they are certified and may be paid under TRICARE for health care services. There are two kinds of non-network providers:

• Participating—Participating providers participate in TRICARE and agree on a case-by-case basis to accept assignment. "Accepting assignment" means that they accept the TMAC as their full fee for care.
• Non-participating—A non-participating provider furnishes health care services or supplies to TRICARE beneficiaries but has not signed a contract and does not agree to accept assignment.

When a Provider Balance Bills

When a provider chooses not to accept assignment, they do not agree to accept TMAC as payment in full and are legally permitted to bill the beneficiary fifteen percent above TMAC for the remainder of charges for the service rendered. This is called balance billing.

It is important for beneficiaries to understand these provider types when seeking care. Seeing a non-network provider can be risky and the beneficiary may pay much more than a visit to a network provider.

Beneficiaries who suspect a provider is balance billing when they have accepted assignment should contact TriWest immediately. Beneficiaries may write to TriWest and include a copy of the explanation of benefits, as well as:

• Name of sponsor
• Sponsor’s Social Security Number
• Patient Name
• Patient date of birth
• Claim number
• Date of service
• Provider name

Please send letters to:

TriWest Healthcare Alliance
Attn: Claims/TFL
PO Box 43770
Phoenix, AZ 85080

For more information please visit www.triwest.com or call 1-888-TRIWEST (1-888-874-9378).