TRICARE Claims and Billing Guide (2026)
*Disclaimer: TRICARE.com is an independent reference site and is not affiliated with the Department of Defense or the official TRICARE program. For official policy and the most current data, visit TRICARE.mil.*
## Quick answer In most cases, TRICARE providers file claims for you, and you pay only your designated cost-share or copayment at the time of service. If you see a non-network provider or receive care overseas, you may need to pay the full bill upfront and file a manual claim for reimbursement with your regional contractor (Humana Military in the East or TriWest in the West).
In detail
The billing process varies significantly depending on your plan (Prime vs. Select) and the type of provider you visit (Network vs. Non-Network).
### Who Files the Claim? * **Network Providers:** These doctors and facilities have a contract with TRICARE. They are required by law to file claims for you. You should never have to file paperwork for a network visit. * **Non-Network Providers:** These providers do not have a contract. While some may file for you as a courtesy, many will require you to pay the full 2026 allowable charge upfront. You must then submit **DD Form 2642** to your regional contractor to get paid back. * **Pharmacy:** Express Scripts handles pharmacy claims. Retail network pharmacies file automatically; for home delivery, you pay your copay via the Express Scripts portal.
### Regional Contractors for 2026 Claims are processed based on where you live. As of the T-5 contract implementation: * **TRICARE East:** Managed by **Humana Military**. * **TRICARE West:** Managed by **TriWest Healthcare Alliance** (which replaced HNFS in 2025). * **Overseas:** Managed by **International SOS**.
### Deductibles and Cost-Shares (2026 Rates) Your "bill" is often just your cost-share. These amounts depend on your "Group" (Group A joined before 2018; Group B joined after): * **TRICARE Prime:** Active Duty Service Members (ADSMs) pay $0. Active Duty Family Members (ADFMs) usually pay $0 for in-network care, provided they have a referral. * **TRICARE Select:** For Group A ADFMs in 2026, outpatient network copays typically range from $30 to $40 per visit after the annual deductible is met. * **Point-of-Service (POS):** If a Prime enrollee sees a specialist without a referral, they will face a $300 individual deductible and 50% cost-shares.
### Timelines for Filing You must submit manual claims within a specific window or they will be denied: * **United States/U.S. Territories:** One year from the date of service. * **Overseas:** Three years from the date of service.
## Who this applies to * **TRICARE Prime Enrollees:** Usually experience "invisible" billing unless they use Point-of-Service options or unauthorized ER visits. * **TRICARE Select Enrollees:** Frequently interact with billing, especially when managing annual deductibles and outpatient cost-shares. * **TRICARE For Life (TFL) Users:** Medicare is the primary payer; TRICARE acts as the secondary payer and processes claims automatically after Medicare pays its portion. * **Overseas Beneficiaries:** Often must pay 100% of costs to foreign providers in local currency and file for reimbursement in U.S. dollars.
Common scenarios
### Scenario 1: Network Specialist Visit (East Region) Jane is a TRICARE Select (Group A) spouse in Virginia. She sees a network dermatologist. The doctor’s office files the claim with **Humana Military**. The allowable charge is $150. Jane pays her 2026 copay of **$37** at the desk. Humana Military pays the remaining $113 directly to the doctor.
### Scenario 2: Non-Network Urgent Care (West Region) Mark is a TRICARE Select retiree in Arizona. He visits a non-network urgent care clinic. The clinic charges $200 and refuses to file a claim. Mark pays the **$200** out of pocket. He submits DD Form 2642 to **TriWest**. Because the "allowable charge" for that service is $160, TRICARE pays Mark back $120 (his $160 allowable amount minus his 25% retiree cost-share). Mark is responsible for the $40 difference plus his cost-share.
### Scenario 3: Overseas Emergency An AD spouse in Germany visits a local hospital for an emergency. She pays 500 Euros upfront. She submits the claim to **International SOS** with an English translation of the bill. TRICARE reimburses her the full amount (converted to USD) because it was a verified emergency.
## Related terms * **Allowable Charge:** The maximum amount TRICARE will pay for a specific medical service. * **Explanation of Benefits (EOB):** A statement sent to you after a claim is processed, showing what TRICARE paid and what you owe. * **Catastrophic Cap:** The maximum out-of-pocket amount a family pays each calendar year for covered TRICARE services. * **Balance Billing:** When a non-network provider bills you for the difference between their charge and the TRICARE allowable charge (limited to 15% for "participating" non-network providers). * **Other Health Insurance (OHI):** If you have another plan (like through an employer), TRICARE by law must pay last.
## Sources * **TRICARE.mil Claims Overview:** https://tricare.mil/claims * **Humana Military (East):** https://www.humanamilitary.com/ * **TriWest Healthcare Alliance (West):** https://www.triwest.com/ * **International SOS (Overseas):** https://www.tricare-overseas.com/