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Become A TRICARE Provider
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Overview
Role of Managed Care Support Contractor
A “Provider” as Defined by TRICARE
Differences Between TRICARE-Certified and TRICARE-Contracted
Becoming TRICARE Certified
Becoming A TRICARE Network Provider
Reimbursement Methodology
Claims Process
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Overview |
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TRICARE is the health care program for active duty and retired members of the uniformed services, their families, and survivors. TRICARE’s primary objectives are to optimize the delivery of health care services in the direct care system for all Military Health System (MHS) beneficiaries and attain the highest level of patient satisfaction through the delivery of a world-class health care benefit. TRICARE brings together the health care resources of the Army, Navy, Air Force, and Coast Guard and supplements them with civilian health care professionals to provide timely access and high quality service while maintaining the capability to support military operations. The program is available worldwide and managed regionally in six separate TRICARE regions—TRICARE North, TRICARE South, TRICARE West, TRICARE Europe, TRICARE Pacific, and TRICARE Latin America/Canada—jointly by the TRICARE Management Activity (TMA) and TRICARE Regional Offices.
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Role of the Managed Care Support Contractor |
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Humana Military Healthcare Services, Inc. (Humana Military) is the civilian managed care support contractor (MCSC) responsible for administering the TRICARE program to more than 2.7 million TRICARE beneficiaries within the TRICARE South Region. This includes Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi, Oklahoma, South Carolina, Tennessee (except the Fort Campbell area), and a major portion of Texas (except for the extreme southwestern El Paso area). |
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Network Subcontractors and Vendors |
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ValueOptions, Inc., (ValueOptions) is Humana Military’s behavioral health care partner in the TRICARE South Region. ValueOptions is the largest privately held behavioral health managed care company in the nation. |
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PGBA, LLC (PGBA) is Humana Military’s claims processing partner in the South Region. PGBA is a fiscal intermediary for the military’s TRICARE health benefits program and is one of the largest subsidiaries of BlueCross BlueShield of South Carolina. |
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A "Provider" as Defined by TRICARE |
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TRICARE defines a provider as a person, business, or institution that provides or gives health care. At a minimum, all TRICARE providers must be authorized/certified under TRICARE Regulation and must have their authorized/certification status verified by the Managed Care Support Contractor assigned responsibility within the specified region, which is Humana Military for the South.
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Differences Between TRICARE-Certified and TRICARE-Contracted Providers |
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A TRICARE-certified provider is a facility, doctor or other healthcare professional that meets the licensing and certification requirements of TRICARE regulations and practices for that area of healthcare.
TRICARE-certified healthcare providers may or may not agree to "accept assignment" — that is, accept the TRICARE maximum allowable charge as payment in full for services. If they don't agree, then they are considered authorized, non-participating providers. They may elect to accept assignment on a claim-by-claim basis. These are also known as TRICARE-certified, non-network providers.
In other words, just because a provider is TRICARE-certified does not mean that the provider is contracted with TRICARE.
A TRICARE-contracted provider is a TRICARE-certified provider who has a contract agreement with a TRICARE Prime Contractor. This provider agrees to accept the TRICARE maximum allowable charge as payment in full and submit claim forms for beneficiaries. A TRICARE-contracted provider is an authorized, participating network provider.
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Becoming TRICARE Certified |
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In order to submit claims, interested providers need only to complete the appropriate form available from PGBA to become “TRICARE Certified”. Once on the PGBA Website, providers can easily determine the appropriate form based on the following criteria: |
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Individual Application - doctors, dentists, therapists, counselors and nurses. |
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Group Application - two or more individual providers working under a Tax ID Number. |
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Supplier Application - ambulances, labs, portable x-ray suppliers, pharmacies and durable medical equipment suppliers. |
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Institutional Application - hospitals, ambulatory surgical centers, skilled nursing facilities, birthing centers, hospice and home health agencies. |
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Access the PGBA Provider Forms Page
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Becoming A TRICARE Network Provider |
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TRICARE certified medical/surgical providers interested in joining the Humana Military network for the South region can communicate their interest by completing a simple online inquiry. TRICARE network providers must agree to submit claims electronically.
Interested providers can learn more about electronic claims submission, along with the numerous other web-based services available to TRICARE providers by referencing information found within an online version of the TRICARE Provider Handbook.
A TRICARE certified behavioral/mental health provider can inquire about network criteria and/or learn how to request an application from information contained within the following ValueOptions web page.
Humana Military, along with our subcontractors and vendors invite all certified providers with an interest in becoming a network provider to follow the appropriate course as outlined above. We look forward to each and every inquiry.
Note: It is important that providers receive final notification of their contract effective date as a TRICARE Network Provider before rendering care to TRICARE Prime beneficiaries.
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Reimbursement Methodology |
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By TRICARE definition, Reimbursement Methodology is the maximum amount TRICARE will cover for nationally established fees (i.e. fees for professional services). CMAC is the TRICARE allowable charge for covered services when appropriately applied to services priced under CMAC. |
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Claims Processing |
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TRICARE is an industry leader in claims processing timeliness. The TRICARE Program provides fast and consistent adjudication with over 99 percent of claims paid within 30 days, and all within 60 days. PGBA is the claims processor for the South Region. Humana Military also offers several innovative solutions to allow providers to file claims electronically.
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