Provider Handbook

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Providers who request approval as TRICARE authorized providers but are denied approval by either TMA or Humana Military may appeal those decisions and request a reconsideration. Provider sanction determinations occur when providers are expelled from TRICARE. Providers may be sanctioned by TRICARE because of failure to maintain credentials, provider fraud, abuse, conflict of interest, or other reasons. Only the provider or his or her representative can appeal. If the sanctions are appealed, an independent hearing officer will conduct a hearing administered by the TMA Appeals and Hearings Division.

Providers who are not eligible for authorization by TRICARE because of fraud and abuse against another federal or federally funded program or a state or local licensing authority (e.g., Medicare or Medicaid) may not appeal through the TRICARE system. Determination is the responsibility of the uniformed services.

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• Point-of-service determinations, with the exception of whether services were related to an emergency and therefore exempt from the requirement for referral and authorization
• Allowable charges (the TRICARE allowable cost or charge for services or supplies is established by regulation)
• A beneficiary’s eligibility, since this determination is the responsibility of the uniformed services
• Provider sanction (the provider is limited to exhausting administrative appeal rights)
• Network provider/contractor disputes
• Denial of services from an unauthorized provider
• Denial of a treatment plan when an alternative treatment plan is selected
• Denial of services by a PCM

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If the beneficiary did not know, or could not reasonably be expected to know, that certain services were potentially excludable from the basic TRICARE program by reason of being not medically necessary, not provided at an appropriate level, custodial care, or other reason relative to reasonableness, necessity, or appropriateness (hereafter, all such services will be referred to as not medically necessary), then the beneficiary will not be held liable for such services and, under certain circumstances, payment may be made for the excludable services as if the exclusion for such services did not apply.

• If both the non-network participating provider and the beneficiary knew the services were excluded
• If the beneficiary did not notify the non-network participating provider of having TRICARE, or
• If the beneficiary knew the services were excluded but the non-network participating provider did not

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