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 Management Activity (TMA) and TRICARE Regional Offices jointly manage these regions.
Partnership of Humana Government Business (HGB) and InStil Health TRICARE HealthCare Service
HGB 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:
To learn more, visit www.humana-military.com.
InStil Health TRICARE HealthCare Services is a subcontractor to HGB, who is responsible for contracting, credentialing and managing the TRICARE Network in South Carolina.
ValueOptions is HGB's behavioral health care partner in the TRICARE South Region. ValueOptions is the largest privately held behavioral health managed care company in the nation. www.valueoptions.com
PGBA, LLC (PGBA) is HGB'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. www.mytricare.com
A "Provider" as Defined by TRICARE
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 regulations 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 and InStil Health TRICARE HealthCare Services in South Carolina.
Differences Between TRICARE-Certified and TRICARE-Contracted Providers
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.
A TRICARE-contracted provider is a TRICARE-certified provider who has a contract agreement with HGB or InStil Health TRICARE HealthCare Services. This provider agrees to accept the negotiated rate as payment in full and submit claim forms for beneficiaries. A TRICARE-contracted provider is an authorized, participating network provider.
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 Web site, providers can easily determine the appropriate form based on these criteria:
- Individual Application - doctors, dentists, therapists, counselors and nurses
- Group Application - two or more individual providers working under a tax ID number
- Supplier Application - ambulances, labs, portable X-ray suppliers, pharmacies and durable medical equipment suppliers
- Institutional Application - hospitals, ambulatory surgical centers, skilled nursing facilities, birthing centers, hospice and home health agencies
Access the PGBA Provider Forms page.
Becoming a TRICARE Network Provider
TRICARE certified medical/surgical providers interested in joining the TRICARE network in South Carolina can communicate their interest by completing a contact form. Provider relations staff will supply details on the contracting process and requirements for TRICARE network providers such as 100% electronic claims submissions, and consult returns for military-enrolled members.
TRICARE Provider Handbook:
TRICARE Provider Forms: