Non Participating DME Suppliers

This notice is to remind non‑participating Durable Medical Equipment (DME) suppliers of important TRICARE reimbursement and balance‑billing requirements that differ from Medicare rules. These requirements apply even if your organization currently bills Medicare as a non‑participating supplier.

Background

Medicare non‑participating suppliers are accustomed to applying the Medicare limiting charge when billing beneficiaries for services. However, certain categories of DME do not have a Medicare limiting charge. In those cases, suppliers may be able to bill the Medicare beneficiary their full charge (subject to Medicare’s rules).

TRICARE Requirements

Even when Medicare does not impose a limiting charge on a specific DME item, TRICARE does. All non‑participating DME suppliers must comply with TRICARE's statutory balance‑billing limit, regardless of Medicare rules.

Key points:

• TRICARE’s balance‑billing limit is 115% of the TRICARE‑allowable amount.

• This limit applies to all non‑participating suppliers, including those who also bill Medicare as non‑participating.

• The TRICARE balance‑billing limit overrides the absence of a Medicare limiting charge on certain DME items.

• Suppliers may not bill TRICARE beneficiaries more than 15% above the TRICARE‑allowable, even if Medicare would permit billing above its allowable.

• Violations of TRICARE balance‑billing rules may result in recovery actions, sanctions, or other compliance follow‑up.

What This Means for Your Organization

Before billing a TRICARE beneficiary for DME:

1. Determine the TRICARE‑allowable amount for the item being provided.

2. Ensure that any billed amount to the beneficiary does not exceed 115% of that allowable.

3. Adjust your billing processes and internal controls to prevent charges above the TRICARE limit.

4. Educate billing staff so they understand the difference between Medicare and TRICARE rules for non‑participating suppliers.

Example

If the TRICARE‑allowable amount for an item is $200:

• Maximum permitted charge to the beneficiary = $230.

• Even if Medicare has no limiting charge on that item, TRICARE’s limit still applies.