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Provider Handbook
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Previous Page Table of Contents Next Page
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Appeals
Proper Appealing Parties
Medical Necessity Determinations
Factual Determinations |
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Appeals |
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TRICARE beneficiaries have the right to appeal decisions made by the TMA or Humana Military for another opinion on the decision. The appeals process varies, depending on whether the denial of benefits involves medical necessity determination, factual determination, provider authorization, or a provider sanction. All initial and appeal denials explain how, where, and by when to file the next level of appeal. An appeal cannot challenge the propriety, equity, or legality of any provision of law or regulation. |
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Proper Appealing Parties |
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- The TRICARE beneficiary (including minors)
- The non-network participating (accepts assignment) provider of services
- A non-network participating (accepts assignment) provider appealing a preadmission/preprocedure denial (when services have not been rendered)
- A provider that has been denied approval as a TRICARE-authorized provider or who has been terminated, excluded, suspended, or otherwise sanctioned
- A person who has been appointed in writing by the beneficiary to represent him or her in the appeal
- An attorney filing on behalf of a beneficiary
- A custodial parent or guardian of a beneficiary under 18 years of age
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A network provider is never an appropriate appealing party unless the beneficiary has appointed the provider, in writing, to represent him or her for the purpose of the appeal. To avoid possible conflict of interest, an officer or employee of the United States—such as an employee or member of a uniformed service, including an employee or staff member of a uniformed services legal office, or a beneficiary counseling and assistance coordinator, subject to exceptions in Title 18, United States Code, Section 205—is not eligible to serve as a representative unless the beneficiary is an immediate family member. |
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Medical Necessity Determinations |
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Medical necessity determinations are based solely on medical necessity—whether, from a medical point of view, the care is appropriate, reasonable, and adequate for the beneficiary’s condition. Generally, determinations relating to health benefits are considered medical necessity determinations. There are expedited procedures for appealing decisions denying requests for prior authorization of services and requests for continued inpatient stays. If an expedited appeal is available, the initial and appeal denial decisions will fully explain how to file an expedited appeal. |
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Factual Determinations |
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Factual determinations involve issues other than medical necessity. Some examples of factual determinations include: coverage issues (i.e., determining whether the service is covered under TRICARE policy or regulation), all foreign claims determinations, and denial of a provider’s request for approval as a TRICARE-authorized provider. |
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Last Update: July, 2007
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