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Tricare Help: When your doctor wants more than Tricare pays

Q. I have an excellent doctor who wants his bills paid in full regardless of the amount any insurance plan pays. He won’t accept the amount Tricare allows as full payment or even the extra 15 percent that Tricare lets a nonparticipating provider charge. I don’t mind paying the difference to keep his services. Can I?

A. The Defense Department’s Office of Health Affairs says that as long as your doctor is a Tricare-authorized provider, you can continue to use his services. There are two kinds of providers: Participating providers, who agree to accept Tricare payments, and nonparticipating providers, who do not.

An authorized provider who agrees to participate in Tricare signs a legally binding agreement to accept the amount Tricare allows for covered services. He may not charge more than Tricare allows on a participating claim.

An authorized provider who chooses not to participate on a Tricare claim is permitted to charge a beneficiary up to, but not more than, 15 percent — called the limiting charge — over the amount Tricare allows for covered services on that claim. Tricare may not pay any part of that additional amount.

A nonparticipating authorized provider may be paid more than the limiting charge permits only if the patient submits an official authorization form with each such claim. Contact your regional Tricare office for details.

Q. Does Tricare cover the shingles immunization? If so, what are the rules?

A. Yes. The patient must be at least 60 years old, the shot must be administered in the physician’s office and the physician must provide the vaccine. The physician should include the cost of the vaccine as a separate item on the bill for the immunization.

Some beneficiaries have had problems getting immunized because of the requirement that the physician must provide the vaccine, Zostavax.

But Zostavax is a medical supply item, not a Tricare pharmacy item, so beneficiaries can’t file reimbursement claims. The physician must do that.

Tricare can tell you or the physician the exact amount it will reimburse for the vaccine.

James E. Hamby Jr. may be reached by writing to Tricare Help at tricarehelp@militarytimes.com.