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). View TRICARE's online directory to locate a BCAC.
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 (e.g., a chiropractor). When services are denied based on a medical necessity or 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.
Your appeal must meet the requirements listed in Figure 7.1.
TRICARE Appeal Requirements
Figure 7.1
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. 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 7.2 and 7.3 for addresses to submit different types of appeals.
3
The issue in dispute must be an appealable issue. The following are non-appealable 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 explanation of benefits (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.
