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 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.
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
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, which is available on Humana Military’s Web site. 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).
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The appeal must be in writing. See Figure 6.2 for addresses to submit different appeals. |
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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
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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 EOB 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 particular deadlines. If you are not satisfied with a decision rendered on an appeal, there are further levels of appeal. For specific information about filing an appeal the South 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 non-expedited review of a denial must be filed no later than 90 days after receipt of the initial denial.
Appeals should contain the following:
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Beneficiary’s name, address, and telephone number
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Sponsor’s Social Security number (SSN)
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Beneficiary’s date of birth
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Beneficiary’s or appealing party’s signature
A description of the issue or concern must include:
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The specific issue in dispute
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A copy of the previous denial determination notice
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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
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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, Inc.
c/o PGBA 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
Claims Appeals
P.O. Box 86508
Phoenix, AZ 85080 |
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
Claims Appeals
P.O. Box 86508
Phoenix, AZ 85080 |
Prior Authorization Appeals:
Health Net Federal Services, Inc.
c/o PGBA, 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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