Tricare - non par provider - Please help!

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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?
 

michellepilcher

Networker
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Location
Anchorage , AK
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My question is if we accept assignment on our claim form are we considered non par providers? Short answer, yes.
and with out box being checked yes on the claim form we should not be collecting more than allowed? Without it being checked, I would take the co-pay, bill the claim then bill the remaining after it processes
And she's wrong. They will not pay the patient, they will pay the provider.

You can see Tricare patients without being in network. Bill your normal amount (what ever that is). Take the allowed amount x 115% and that is the max you can charge a patient. Do not check accept assignment. When you check accept assignment, you are agreeing to take the allowed and not bill the rest to the patient.


  • Nonparticipating Provider: An authorized hospital, institutional provider, physician, or other provider that furnishes medical services (or supplies) to TRICARE beneficiaries, but has not signed an agreement and does not agree to accept assignment. A nonparticipating provider may balance bill up to 115 percent of the TRICARE allowable charge.
  • Participating Provider: Providers who participate in TRICARE or accept assignment agree to file claims for TRICARE beneficiaries, accept payment directly from TRICARE and accept the TRICARE-allowable charge as payment in full for their services. Non-network individual providers may participate on a case-by-case basis. Providers must seek applicable copayments, cost-shares and deductibles from the beneficiary. Hospitals that participate in Medicare must, by law, also participate in TRICARE for inpatient care. For outpatient care, they may or may not participate.
 
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