Making the Most of Tricare Insurance: A Guide to Utilizing Therapy Services with Out-of-Network Providers

Navigating the intricacies of healthcare insurance can often feel like a daunting task, especially when seeking therapy services with an out-of-network provider. However, for those covered by Tricare Insurance, accessing quality mental health care outside of the network is not only possible but can also be a straightforward process. In this guide, we'll explore how individuals with Tricare Prime and Tricare Select can maximize their benefits to receive therapy services from out-of-network providers.

Understanding Tricare Prime and Tricare Select: 

Tricare Prime and Tricare Select are two primary healthcare plans offered to military service members, retirees, and their families. While Tricare Prime operates similarly to an HMO plan with designated network providers, Tricare Select offers greater flexibility, allowing beneficiaries to choose their healthcare providers, including those outside of the network.

Utilizing Tricare Prime for Out-of-Network Therapy Services:

If you are enrolled in Tricare Prime and wish to seek therapy services from an out-of-network provider, it's essential to understand the process and potential costs involved:

1. Obtain a Referral:

Tricare Prime typically requires beneficiaries to obtain a referral from their primary care manager (PCM) before seeking services from a specialist, including therapists. Discuss your need for therapy with your PCM and request a referral to an out-of-network provider if necessary.

2.Deciding to not obtain a Referral: 

You can directly select a provider without a referral if you choose to. However, you will be responsible to cover the deductible and 50% of each visit after the deductible is met.

3. Check Coverage and Costs:

Before scheduling an appointment, verify your coverage and potential out-of-pocket costs for out-of-network therapy services. While Tricare Prime may cover a portion of the expenses, you may still be responsible for copayments, deductibles, or coinsurance.

4. Submit Claims for Reimbursement:

After receiving therapy services, you or your therapist will need to submit a claim to Tricare for reimbursement. Keep detailed records of your sessions and any related expenses to facilitate the reimbursement process.

Utilizing Tricare Select for Out-of-Network Therapy Services: 

Tricare Select offers beneficiaries greater flexibility in choosing their healthcare providers, including therapists who are not part of the Tricare network. Here's how to make the most of Tricare Select for out-of-network therapy services:

1. Choose Your Provider:

With Tricare Select, you have the freedom to select any licensed therapist or mental health provider, regardless of whether they are in-network or out-of-network.

2. Verify Coverage and Costs:

Before scheduling an appointment with an out-of-network therapist, verify your coverage and understand your financial responsibilities, including deductibles, cost-sharing, and any applicable copayments or coinsurance.

Tricare Select clients can expect to pay 20% copay for each session.

3. Submit Claims for Reimbursement:

After receiving therapy services, you or your therapist will need to submit a claim for reimbursement to Tricare. Ensure that all necessary documentation, including invoices and treatment records, is included to expedite the reimbursement process.

Accessing therapy services with an out-of-network provider through Tricare Insurance, whether Prime or Select, can offer valuable benefits and flexibility for beneficiaries. By understanding the process, verifying coverage, and submitting claims for reimbursement promptly, individuals can effectively utilize their Tricare benefits to prioritize their mental health and well-being. If you have any questions or need assistance navigating your Tricare coverage for therapy services, don't hesitate to reach out to your Tricare representative or healthcare provider for guidance.