TRICARE Prime Handbook

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Information and Assistance


Beneficiary Counseling and Assistance Coordinators
Beneficiary counseling and assistance coordinators (BCACs) can help you with TRICARE and Military Health System inquiries and concerns and can advise you about obtaining health care. BCACs are located at military treatment facilities (MTFs) and at the TRICARE Regional Offices (TROs). To locate a BCAC, visit TRICARE.


Appealing a Decision

If you believe a service or claim was improperly denied, in whole or in part, you (or another appropriate party) may file an appeal. An appeal must involve an appealable issue. For example, you have the right to appeal TRICARE decisions regarding the payment of your claims.

You also may appeal the denial of a requested authorization of services even though no care has been provided and no claim submitted. There are some things you may not appeal. For example, you may not appeal the denial of a service provided by a health care provider not eligible for TRICARE certification.

When services are denied based on a medical necessity or a benefit decision, you are notified automatically in writing. The notification will include an explanation of what was denied or why a payment was reduced and the reasoning behind that decision.

Appeal Requirements
Your appeal must meet the requirements listed in Figure 6.1.
     
TRICARE Appeal Requirements                                                                                            Figure 6.1

1

An appropriate appealing party must submit the appeal. Proper appealing parties include:
  • You, the beneficiary
  • Your custodial parent (if you are a minor) or your guardian
  • A person appointed in writing by you to represent you for the purpose of the appeal
  • An attorney filing on your behalf
  • Non-network participating providers
If a physician or other party is going to submit the appeal, you must complete and sign the Appointment of Representative and Authorization to Disclose Information form, which is available on Humana Military's Web site. If the appeal is submitted without this form, it will not be processed. Note: Network providers are not appropriate appealing parties (unless appointed by you in writing).

2

 The appeal must be in writing. See Figure 6.2 for addresses to submit different appeals.

3

The issue in dispute must be an appealable issue. The following are nonappealable issues:

  • Allowable charges
  • Eligibility
  • Denial of services from an unauthorized provider
  • Denial of treatment plan when an alternative treatment plan is selected
  • Refusal by a PCM to provide services or refer a beneficiary to a specialist
  • Point of service issues, except for whether the services were related to an emergency

4

The appeal must be filed in a timely manner. An appeal must be filed within 90 days after the date on the EOB or denial notification letter.

5

There must be an amount in dispute to file an appeal. In the case involving an appeal of a denial of an authorization in advance of receiving the actual services, the amount in dispute is deemed to be the estimated TRICARE allowable charge for the services requested. There is no minimum amount in dispute necessary to request a reconsideration.

Filing an Appeal
Appeals must be filed with Humana Military within particular deadlines. If you are not satisfied with a decision rendered on an appeal, there are further levels of appeal. For specific information about filing an appeal in
your region, contact Humana Military.

Prior authorization denial appeals may be either expedited or non-expedited, depending on the urgency of the situation. You or an appointed representative must file an expedited review of a prior authorization denial within three calendar days after receipt of the initial denial. A non-expedited review of a denial must be filed no later than 90 days after receipt of the initial denial.

Appeals should contain the following:
  • Beneficiary’s name, address, and telephone number
  • Sponsor’s Social Security number (SSN)
  • Beneficiary’s date of birth
  • Beneficiary’s or appealing party’s signature
A description of the issue or concern must include:
  • The specific issue in dispute
  • A copy of the previous denial determination notice
  • Any appropriate supporting documents

Send your appeal to Humana Military. See Figure 6.2 for appeals filing information.
   
Regional Appeals Filing Information                                                                                        Figure 6.2

TRICARE North Region

TRICARE South Region

TRICARE West Region

Claims Appeals:
Health Net Federal Services, Inc. c/o PGBA LLC/TRICARE Claims Appeals P.O. Box 870148 Surfside Beach, SC 29587-9748

Claims Appeals Fax:
1-888-458-2554

Prior Authorization Appeals:
Health Net Federal Services, Inc. c/o PGBA, LLC/TRICARE Authorization Appeals P.O. Box 870142 Surfside Beach, SC 29587-9742

Prior Authorization Appeals Fax:
1-888-881-3622

Claims Appeals:
TRICARE South Region Appeals P.O. Box 202002 Florence, SC 29502-2002

Prior Authorization Appeals: Humana Military Healthcare Services Attn: Clinical Appeals P.O. Box 740044 Louisville, KY 40201-9973

Behavioral Health Appeals: ValueOptions Behavioral Health Attn: Appeals and Reconsideration Department P.O. Box 551138 Jacksonville, FL 32255-1138

Claims Appeals:
TriWest Healthcare Alliance Claims Appeals P.O. Box 86508 Phoenix, AZ 85080

Prior Authorization Appeals: TriWest Healthcare Alliance Claims Appeals P.O. Box 86508 Phoenix, AZ 85080

Filing a Grievance
A grievance is a written complaint or concern about a nonappealable issue regarding a perceived failure by any member of the health care delivery team—including TRICARE authorized providers, military providers, regional
contractors, or subcontractor personnel—to provide appropriate and timely health care services, access or quality, or to deliver the proper level of care or service. The grievance process allows full opportunity to report in writing any concern or complaint regarding health care quality or service. Any TRICARE civilian or military provider, TRICARE beneficiary, sponsor, parent or guardian, or other representative of an eligible dependent child may file a grievance. Humana Military is responsible for the investigation and resolution of all grievances.Grievances are resolved no later than 60 days from receipt. Following resolution, the party who submitted the grievance will be notified of the review completion.

Grievances may include such issues as:
  • The quality of health care or services aspects like accessibility, appropriateness, level, continuity, or timeliness of care
  • The demeanor or behavior of providers and their staff
  • The performance of any part of the health care delivery system
  • Practices related to patient safety

When filing a grievance, include the following:
  • The beneficiary’s name, address, and telephone number
  • Sponsor’s SSN
  • Beneficiary’s date of birth
  • Beneficiary’s signature
  • A description of the issue or concern must include:
    • Date and time of the event
    • Name of the provider(s) and/or person(s) involved
    • Location of the event (address)
    • The nature of the concern or complaint
    • Details describing the event or issue
    • Any appropriate supporting documents
File your grievance with Humana Military. See Figure 6.3 for grievance filing information.
 
Regional Grievance Filing Information                                                                                       Figure 6.3

TRICARE North Region

TRICARE South Region

TRICARE West Region

All grievances should be
addressed to:

Health Net Federal Services, Inc. c/o PGBA, LLC/TRICARE Grievance P.O. Box 870150 Surfside Beach, SC 29587-9750

Submit online at:
 Health Net Federal Services

Submit by fax:
1-888-317-6155

Submit your grievance in
writing to the nearest location:

Regional Grievance Coordinator Humana Military Healthcare Services 8123 Datapoint Drive Suite 400 San Antonio, TX 78229

For behavioral health care concerns, send your
information to:

Grievance Specialist
ValueOptions
P.O. Box 551188
Jacksonville, FL 32255-1188

All grievances should be addressed to:

TriWest Healthcare Alliance Attn: Customer Relations Dept. P.O. Box 86036 Phoenix, AZ 85080


Reporting Suspected Fraud and Abuse
Fraud happens when a person or organization deliberately deceives others to gain some sort of unauthorized benefit. Health care abuse occurs when providers supply services or products that are medically unnecessary or that do not meet professional standards.

Beneficiaries are important partners in the ongoing fight against fraud and abuse. Because an explanation of benefits (EOB) is a tangible statement of services/supplies received, it is one of the first lines of defense against health care fraud. Each EOB provides a tollfree number to call if you have questions about services you believe are billed fraudulently, or you can access the TRICARE Program Integrity for direct links to each contractor’s fraud and abuse reporting office. Through Humana Military's Web site, you can use claims tools to view your EOBs, claims history, and track TRICARE costs paid. We strongly encourage you to read your EOBs carefully.

Report suspected fraud and abuse to Humana Military. See Figure 6.4 for details.

To report fraud or abuse regarding the pharmacy program, contact ESI:
You also can report fraud or abuse issues directly to TRICARE at  fraudline@tma.osd.mil.

Regional Fraud and Abuse Reporting Information                                                               Figure 6.4

TRICARE North Region

TRICARE South Region

TRICARE West Region
  • Call 1-800-333-1620
  • Mail information to:
    Humana Military Healthcare
    Services, Inc.
    Attn: Program Integrity
    500 W. Main Street, 19th floor
    Louisville, KY 40202
  • Call 1-888-584-9378
    Fax: 1-602-564-2458
  • Report online at: 
    TRIWEST 

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Last Reviewed: July 11, 2008