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Appealing a Decision


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 (e.g., a chiropractor). When services are denied based on a medical necessity or 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 7.1.

Figure 7.1 TRICARE Appeal Requirements
   

1
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. 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).

2

 The appeal must be in writing. See Figure 7.2 and 7.3 for addresses to submit different appeals.

3
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

4

 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.

5

 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: Active Duty Service Members

Your service point of contact (SPOC) will tell you how to file an appeal, if you think you need one. You or your PCM or provider may send additional written information or documentation to support your request for specialty care to the SPOC.

Figure 7.2 Active Duty Appeals Contact Information
 

Service Branch SPOC Contact Information
DoD (Army, Air Force, Navy, Marine Corps) 1-888-MHS-MMSO
(1-888-647-6676)
Written Inquires:
(insert your branch of service)
Point of Contact
Military Medical Support Office
P.O. Box 886999
Great Lakes, IL 60088-6999
Coast Guard 1-888-MHS-MMSO
(1-888-647-6676)
1-800-9HBA-HBA
(1-800-942-2422
NOAA 1-800-662-2267
USPHS 1-800-368-2777, option #2
Active duty service members enrolled at an MTF should appeal to the MTF and not to the MMSO SPOC.

If your request is denied on appeal, you may appeal one more time to the Surgeon General or senior medical officer of your respective service. The address for this second appeal will be provided to you following a denial of the first appeal.

Filing an Appeal: Active Duty Family Members

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 in 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:
  • Beneficiary’s name, address, and telephone number
  • Sponsor’s Social Security number
  • 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 7.3 for appeals filing information.

Figure 7.3 Regional Appeals Filing Information for Family Members
    

TRICARE North Region

TRICARE South Region

TRICARE West Region

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		          
Prior Authorization Appeals Fax:
1-888-881-3622		                   
 

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Last Reviewed: July 30, 2009