Wiki Tricare non par provider - help!

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Brittneybrookebarber

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We are OON with Tricare but do accept assignments, our box 27 on the HCFA form is checked yes.
our oon fee is $115.00 but Tricares allowed amount is $79.80
So when out tricare patients come in we take their co insurance base off of our 115 and not the allowed amount which we have agreed to do according to our claim form.
I had a parent pull the tricare non par provider regulations and bring them in stating we are allowed to charge up to 15% more of the allowed amount (79.80 but our box 27 is checked yes)
I brought this to my "billing managers" attention and she stated we are not non par providers and we can charge what we want and if our box 27 was checked no the insurance will cut the patient the check and not us.

My question is if we accept assignment on our claim form are we considered non par providers?
and with out box being checked yes on the claim form we should not be collecting more than allowed?
 
As I understand it, since TRICARE is a government plan, and not commercial insurance, the terms are governed by federal law and not by contract. If you accept assignment, then you have effectively agreed to participate for that particular claim, and are required to accept the terms of the payment and can only bill up to the allowed amount, even if you are not participating with the program. If you do not accept assignment, you are still limited by the federal laws as to how much you are allowed to bill, which is 15% above the allowed amount. Your 'billing manager' is incorrect. You can refer to the link below:


I'd note that the laws apply in a similar way to out-of-network/non-participating providers seeing patients with Medicare and Medicare Advantage plans.
 
Last edited:
thomas7331 said:
As I understand it, since TRICARE is a government plan, and not commercial insurance, the terms are governed by federal law and not by contract. If you accept assignment, then you have effectively agreed to participate for that particular claim, and are required to accept the terms of the payment and can only bill up to the allowed amount, even if you are not participating with the program. If you do not accept assignment, you are still limited by the federal laws as to how much you are allowed to bill, which is 15% above the allowed amount. Your 'billing manager' is incorrect. You can refer to the link below:


I'd note that the laws apply in a similar way to out-of-network/non-participating providers seeing patients with Medicare and Medicare Advantage plans.
Click to expand...



Thank you for the link! I am trying to make sure I have all the information possible before going over her head.
 
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