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Billing Medicare

MTFs may bill non-uniformed services Medicare enrollees directly for emergency treatment at the appropriate full inpatient (FRR) or professional/outpatient (FOR) rate based on Service or NCR MD guidance. Alternatively, MTFs may participate in Medicare or elect to enroll as non-participating providers for certain emergency care, and submit claims to Medicare for care provided to these Medicare enrollees. To do so, they must collect and maintain on file the patient’s DD Form 2569. This contains his/her assignment of benefits required to receive Medicare reimbursement. Medicare claims are based on the Interagency Rates (IAR), and payment from Medicare is payment in full. MTFs may not Balance BillThe practice of a provider billing a beneficiary the difference between the TRICARE allowed amount and the billed charges on a claim. Participating providers and network providers may not collect from all sources an amount which exceeds the TRICARE allowed amount. Non-participating providers may not collect an amount which exceeds the balance billing limit (115% of the allowed charge). If the billed charge is less than the balance billing limit, then the billed charge is the maximum amount that can be collected by the non-participating provider. (See the TRICARE Reimbursement Manual (TRM), Chapter 3, Section 1.)balance bill the patient, except for deductibles and co-payments. 

Billing the U.S. Coast Guard

Per Interagency Agreement (IAA), the U.S. Coast Guard (USCG) reimburses the Army, Navy, Air Force and National Capital Region Medical Directorate (NCR MD) annually, and on a prospective basis, for inpatient and outpatient care provided to USCG eligible beneficiaries at their MTFs. Payments are calculated based on actual prior fiscal year encounter data and DHA UBO rates. They are normalized using the appropriate medical inflation factors, force structure adjustments, and other health insurance (OHI) adjustment (a discount). The USCG directly distributes prospective payment amounts (PPAs) to Army, Navy, Air Force and NCR MD MTFs based on individual treatment Defense Medical Information System [facility] identifier (DMIS ID) PPA calculations. For more information, see the USCG Billing section in the DHA User Guide. The Memorandum of Understanding between the DoD and the U.S. Coast Guard is available upon request to the DHA UBO Help Desk. 

Billing NOAA and USPHS

The Memorandum of Agreement between the Defense Health Agency (DHA) and the Department of Health and Human Services (DHS), US Public Health Service (USPHS) Commissioned Corps, and the National Oceanic and Atmospheric Administration (NOAA) Commissioned Officer Corps regarding participation in TRICARE are available upon request to the DHA UBO Help Desk.

Multi-Site/Regional Billing

Multi-site billing (sometimes referred to as regional billing) allows one facility to perform claims processing for one or more facilities. The concept of Multi-site billing has been accomplished to various degrees by the Services and NCR MD.  There are some key points, though, involved in any arrangement when a facility or agency is contracted to perform this function for another facility. At a minimum: 

  • A written agreement should be in place between the contracting and contracted facility/agency. This agreement is to be approved by the Service or NCR MD Program Managers prior to implementation to ensure it meets UBO compliance requirements. 
  • When a service is contracted out, the contracting facility/agency is ultimately responsible for assuring work is being accomplished within appropriate compliance guidelines. 
  • No military facility performing this service for another MTF should charge anything other than actual cost. The formula for determining the cost of operations is the number of claims divided by the total MEPRS EBH costs. You may need to review your EBH data to ensure it represents your costs. 
  • The facility/agency contracted to perform collections and the contracting facility must have an audit process in place to ensure record documentation supports claims developed. 
  • Accounts receivable processes must separate out claims by facility/agency against which funds were collected. 
  • The contracting facility/agency must receive reports on accounts receivable, metrics reports, and has a right to audit the process for accurate accounting and billing processes. 
  • Quarterly metrics reports data are separated out for each facility/agency for which the claims are processed. 
  • The contracting facility/agency has a right to access data from the contracted facility/agency to assess the effectiveness of third party collection operations for their patient population. These requirements should be included in the contractual agreement. 

For further information, please contact your Service or NCR MD Program Manager.

DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

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