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Balance Billing

What is balance billing?

Balance billing occurs when a provider bills a TRICARE beneficiary for any amount in excess of the TRICARE-allowable charge after TRICARE has processed the claim. This practice is limited by law. TRICARE prohibits the practice of balance billing. Balance billing requirements apply to both network and non-network providers who treat TRICARE beneficiaries, and noncompliance can impact your TRICARE and/or Medicare status.

Network vs. non-network provider responsibilities

Once you sign an agreement to become a TRICARE network provider, you agree to be paid the lesser of the TRICARE maximum allowable charge or your contracted rate. If you are a non-network TRICARE-authorized provider and have agreed to participate on a claim, this means you have agreed to accept the TRICARE-allowable charge as payment in full for this claim and you may not bill patients for any amount in excess of the TRICARE-allowable charge. Non-network providers who do not accept assignment are limited by federal balance billing laws on how much they can bill TRICARE beneficiaries.

Non-participating providers may not balance bill the beneficiary more than 115% of the allowable charge.

Note: When the billed amount is less than 115% of the allowed amount, the provider is limited to billing the billed charge to the beneficiary. The balance billing limit shall be applied to each line item on a claim.