Provider Handbook

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If a provider or beneficiary has a concern about the level or quality of services (or care) received through the TRICARE program, he or she has a right to file a grievance with Humana Military.

A grievance is a written complaint on a nonappealable issue that deals primarily with a perceived failure of a network provider or an employee of Humana Military or its subcontractor(s) to furnish the level or quality of service or care expected by a beneficiary or provider. The following are examples of issues subject to the grievance process:
 

• Complaints concerning the quality of a clinical or non-clinical service received by a beneficiary
• Complaints regarding wait times in a provider’s office, physician or employee behavior, adequacy of facilities, and other similar concerns
• Complaints about the level of customer service provided by a provider, contractor, or subcontractor staff

Grievances do not pertain to claims payment issues or denials of medical treatment authorizations. These are considered to be appeals and are described in the next section.

Grievances are directed first to the TRICARE Service Center (TSC) for resolution. If a complaint is not resolved by the TSC, a written grievance may be filed with the market office. The grievance will be investigated and adjudicated by the appropriate market office within 60 days of its receipt. The parties involved in the grievance will then be informed of the determination. If the parties are still not satisfied, they can request a second-level review.

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