Provider Handbook
 

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Requirements for Appeals and Administrative Reviews Fig. 8.10
 
Reviewable Issues Time Frames Contact Information
  • Claims denied because the service is not covered under TRICARE or exceeds policy limitations/coverage criteria
  • Claims denied as not medically necessary
  • Claims for assistant surgeon charges denied by ClaimCheck
  • Claims processed as point of service only when the reason for dispute is that the care was emergency
  • Requests must be postmarked or received within 90 calendar days of the date of the denial.
  • For TRICARE purposes, a postmark is a cancellation mark issued by the United States Postal Service. If the postmark on the envelope is not legible, the date of receipt is deemed to be the date of filing.
 TRICARE Appeals:
TRICARE South Region
Appeals Department
P.O. Box 202002
Florence, SC 29502-2002
Document Requirements:
  • All appeal/administrative review requests must be in writing and must be signed.
  • All appeal/administrative review requests must state the issue in dispute.
  • Be certain to include a copy of the initial denial (EOB/Provider Remittance Advice) and any additional documentation in support of the appeal.
  • In addition, please provide the following:
    • Sponsor’s Social Security number
    • Beneficiary/patient name
    • Date(s) of service
    • Provider’s address, telephone/fax numbers, and e-mail address, if available
    • Statement of the facts of the request
  • Appeals must be requested by an appropriate appealing party.
Note: The custodial parent of a minor beneficiary is presumed to have been appointed by the beneficiary to represent them in the appeal.
 


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Last Update: July, 2007