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 will be automatically notified in writing. The notification will include an explanation of what was denied or why a payment was reduced and the reasoning behind the decision.
Appeal Requirements
Your appeal must meet the requirements listed in Figure 6.1 Figure 6.1 TRICARE Appeal Requirements
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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
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The appeal must be in writing. See Figure 6.2 for the appeals submission address for your region. |
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The issue in dispute must be an appealable issue. The following are not 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 primary care manager to provide services or refer a beneficiary to a specialist
- Point of service issues, except when services were related to an emergency
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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 or denial notification letter. |
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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 90 days from the date that appears on the explanation of benefits or denial notification letter. If you are not satisfied with a decision rendered on an appeal, there may be further levels of appeal available to you. 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 nonexpedited 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. Figure 6.2 Regional Appeals Filing Information
TRICARE North Region
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TRICARE South Region
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TRICARE West Region
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Claims Appeals:
Health Net Federal Services, LLC
TRICARE Claims Appeals
P.O. Box 870148
Surfside Beach, SC 29587-9748 |
Claims Appeals:
TRICARE South Region Appeals
P.O. Box 202002
Florence, SC 29502-2002 |
Claims Appeals:
TriWest Healthcare Alliance Corp.
Claims Appeals
P.O. Box 86508
Phoenix, AZ 85080 |
Claims Appeals Online
Claims Appeals Fax:
1-888-458-2554 |
Prior Authorization Appeals:
Humana Military Healthcare Services
Attn: Clinical Appeals
P.O. Box 740044
Louisville, KY 40201-9973 |
Prior Authorization Appeals:
TriWest Healthcare Alliance Corp.
Reconsideration Department
P.O. Box 86508
Phoenix, AZ 85080 |
Prior Authorization Appeals:
Health Net Federal Services, LLC
TRICARE Authorization Appeals
P.O. Box 870142
Surfside Beach, SC 29587-9742 |
Behavioral Health Appeals:
ValueOptions Behavioral Health
Attn: Appeals and Reconsideration
Department
P.O. Box 551138
Jacksonville, FL 32255-1138 |
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Prior Authorization Appeals Fax:
1-888-881-3622 |
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