TRICARE Medical Billing Guide

TRICARE Billing Basics for Civilian Providers

TRICARE is the health benefit program for active-duty military service members, retirees, and their families, covering approximately 9.6 million beneficiaries worldwide. The program is managed by the Defense Health Agency (DHA) and administered through regional contractors: Health Net Federal Services (West Region) and Humana Military (East Region). Civilian providers interact primarily with these regional contractors for claim submission, authorization, and payment.

The TRICARE system includes several plan options. TRICARE Prime operates like an HMO for active-duty families and retirees, with a primary care manager (PCM) who coordinates all care. TRICARE Select functions as a PPO for retirees and some family members, offering more flexibility in provider choice. TRICARE for Life provides wrap-around coverage for Medicare-eligible retirees, paying after Medicare processes the claim.

Provider Authorization and Enrollment

Civilian providers must be TRICARE-authorized before billing. Authorization requires a valid professional license, certification or accreditation appropriate to your specialty, an active NPI, and registration through the regional contractor. Submit your authorization application to the appropriate regional contractor (Health Net Federal or Humana Military) based on your practice location. Processing takes 30 to 60 days.

TRICARE maintains two categories of civilian providers: participating (PAR) and non-participating (non-PAR). Participating providers accept the TRICARE-allowed amount (CMAC) as payment in full and file claims on behalf of the beneficiary. Non-participating providers may charge up to 115% of the CMAC for TRICARE Select patients but must accept the CMAC for TRICARE Prime referrals. The financial advantage of participating status includes direct payment from TRICARE and access to more TRICARE beneficiaries.

Active-duty service members receive care at military treatment facilities (MTFs) as a first priority. When the MTF cannot provide a needed service, the beneficiary receives a referral to a civilian provider. These referrals come through the MTF and are documented in the TRICARE system. Without a referral for Prime beneficiaries, your claim will be denied.

Timely Filing and Claim Submission

TRICARE requires claims to be filed within 365 days of the date of service. This one-year deadline applies to all TRICARE plan types. For services that required authorization, the filing deadline runs from the date of service, not the authorization date. Claims filed after 365 days are denied, and TRICARE-authorized providers cannot bill the beneficiary for the denied amount.

Submit electronic claims to the regional contractor using the standard 837P (professional) or 837I (institutional) format. Health Net Federal Services (West Region) uses electronic payer ID 99726. Humana Military (East Region) uses payer ID 99727. TRICARE for Life claims are processed by Wisconsin Physicians Service (WPS) after Medicare pays and use payer ID 99741. Verify the correct payer ID with your clearinghouse based on the beneficiary’s region.

Include the sponsor’s Department of Defense (DOD) Benefits Number (DBN) or Social Security Number (SSN) on the claim. TRICARE is transitioning fully to DBN, which appears on newer beneficiary ID cards. Also include the beneficiary’s relationship to the sponsor and the TRICARE plan type. Missing sponsor information is a common reason for TRICARE claim rejections.

Reimbursement and the CHAMPUS Fee Schedule

TRICARE reimburses civilian providers based on the CHAMPUS Maximum Allowable Charge (CMAC), which is derived from the Medicare fee schedule with some modifications. For most professional services, the CMAC closely mirrors Medicare’s MPFS rates. Some services, particularly those not covered by Medicare, have TRICARE-specific fee schedule amounts set by DHA.

TRICARE publishes its fee schedules annually, with updates taking effect each January. The Defense Health Agency posts maximum allowable charges on the TRICARE provider website. Rates are adjusted by geographic area using the same GPCI (Geographic Practice Cost Index) factors that Medicare uses, so reimbursement for the same CPT code varies by provider location.

Participating providers accept the CMAC as payment in full. Beneficiary cost-sharing varies by plan type. Active-duty service members pay nothing. TRICARE Prime dependents pay copays (typically $12 to $34 per visit for outpatient care). TRICARE Select beneficiaries pay cost shares that vary based on whether they are Group A (enrolled before 2018) or Group B (enrolled 2018 or later) and whether the provider is network or non-network.

Referral and Authorization Requirements

TRICARE Prime requires referrals from the primary care manager for virtually all specialty care. The PCM (either an MTF provider or a civilian network PCM) generates the referral in the TRICARE system, specifying the specialist, the diagnosis, and the number of authorized visits. Without an active referral, TRICARE Prime claims for specialty services are denied.

TRICARE Select does not require referrals for network providers but does require them for some services when using non-network providers. Both TRICARE Prime and Select require prior authorization for specific services including inpatient admissions, some outpatient procedures, behavioral health beyond initial evaluation, and durable medical equipment. Submit authorization requests through the regional contractor’s portal or by phone.

Emergency services do not require prior referral or authorization for any TRICARE plan type. Notify the regional contractor within 24 hours of an emergency admission. Non-emergency care provided without the required referral or authorization is the beneficiary’s financial responsibility for Select plans but cannot be billed to Prime beneficiaries, meaning the provider absorbs the cost.

Appeal Process

TRICARE’s appeal process provides two levels of administrative review. The initial appeal (reconsideration) must be filed within 90 days of the initial claim determination. Submit the appeal in writing to the regional contractor with supporting documentation. The contractor issues a reconsideration decision within 60 days.

If the reconsideration is unfavorable, you can request a formal review by filing a written appeal with DHA within 60 days of the reconsideration decision. DHA conducts an independent review of the case and issues a final decision. For claims exceeding $300, you may request a hearing before an independent hearing officer. The hearing provides an opportunity to present your case in person or by telephone.

TRICARE appeals often involve referral and authorization disputes. When appealing a referral-related denial, include documentation showing that the service was medically necessary and that the beneficiary was unable to obtain a timely referral through normal channels. TRICARE adjudicators have the authority to grant retroactive referrals when documentation supports the medical need for the service.