Allowable Charge
Quick Definition
Maximum amount TRICARE will pay for a covered service.
Video Explanation
Full Definition
The allowable charge is the maximum amount TRICARE will pay for a covered healthcare service or supply. This amount is determined by TRICARE's fee schedule and varies based on geographic location and type of service.
Understanding allowable charges: • TRICARE sets maximum reimbursement rates for all covered services • Network providers agree to accept the allowable charge as payment in full • Non-network providers may charge up to 15% above the allowable charge • Beneficiaries are responsible for copays/cost-shares based on the allowable amount
Example If a doctor visit has an allowable charge of $100 and your cost-share is 20%, you pay $20. If using a non-network provider who charges $115 (15% above allowable), you pay the $20 cost-share plus the additional $15.
Using network providers ensures you only pay your cost-share with no additional balance billing.
Related Questions
How much does TRICARE cost?
Costs vary by plan and beneficiary status. Active duty members have no costs. Retirees and their families pay enrollment fees and cost-shares.
Does TRICARE cover prescriptions?
Yes, TRICARE covers most prescriptions through military pharmacies, network pharmacies, and home delivery.
What is an EOB in TRICARE?
An EOB (Explanation of Benefits) is a statement from TRICARE that details the services billed, amounts paid by TRICARE, and any remaining costs the beneficiary owes.
What is a network provider in TRICARE?
A network provider is a doctor, hospital, or other healthcare provider that has a contract with a TRICARE regional contractor to provide services at negotiated rates.
What is a non-network provider in TRICARE?
A non-network provider is a TRICARE-authorized provider who does not have a contract with the regional contractor, resulting in higher costs and the beneficiary potentially filing their own claims.
What is TRICARE Standard?
TRICARE Standard was the former fee-for-service health plan that allowed beneficiaries to see any TRICARE-authorized provider. It was replaced by TRICARE Select on January 1, 2018.
How to file a TRICARE claim?
Network providers file claims for you. For non-network providers, submit a claim form (DD Form 2642) with an itemized bill to your regional contractor within one year of service.
How to check TRICARE claim status?
Check your TRICARE claim status online through your regional contractor's website, through milConnect, or by calling your contractor's customer service line.
Related Terms
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