When a provider agrees to accept the TRICARE-allowed amount as payment in full. Network providers accept assignment on all claims and non-network providers may choose to accept assignment on a claim-by-claim basis.
Family member of an active duty service member.
A person currently serving in one of the seven uniformed services of the United States under a call or order that does not specify a period of 30 days or less.
A reconsideration request (appeal) from a network provider regarding a claim that has been denied for a service that is not covered or not medically necessary. A network provider may also request an administrative review if a penalty was applied for no authorization and the provider believes the services rendered were due to an emergency.
A review by claims staff to determine if the allowed amounts on a claim are accurate. The beneficiary or the rendering participating provider may request an Allowable Charge Review by phone or in writing to the attention of Claims Correspondence.
The amount TRICARE allows for a covered service or supply. The allowable charge can only be determined once a claim is processed. It is generally the lower of the billed charge, the CHAMPUS Maximum Allowable Charge (CMAC) or a negotiated rate. Other factors include multiple surgical procedure calculations, ambulatory surgery procedure pricing, the Outpatient Prospective Payment System (OPPS) and diagnosis-related group (DRG) pricing for most inpatient hospitals.
A medical facility where surgical procedures are performed that do not require an overnight hospital stay. These facilities are also known as outpatient surgery centers or same day surgery centers.
A formal written request by an appropriate appealing party regarding a claim or authorization denied because it is not a covered benefit or not medically necessary. There are two additional appeal types:
An appeal is also referred to as reconsideration.
Approval given by Health Net after review of submitted documentation to ensure the requested service is a TRICARE-covered benefit and medically necessary for the diagnosis submitted. Certain services require authorization. Synonyms include preauthorization, prior authorization and pre-certification.
A medical or behavioral health provider (such as, an individual professional, facility, lab, supplier, hospital) that TRICARE has verified to meet specific licensing, educational, accreditation, and other requirements. TRICARE can only cover services by authorized providers. All network providers are authorized providers, but not all authorized providers are network providers. An authorized provider is also called a certified provider.