Proper Appealing Parties

• The TRICARE beneficiary (including minors)
• The non-network participating (accepts assignment) provider of services
• A non-network participating (accepts assignment) provider appealing a preadmission/preprocedure denial (when services have not been rendered)
• A provider who has been denied approval as a TRICARE-authorized provider or who has been terminated, excluded, suspended, or otherwise sanctioned
• A person who has been appointed in writing by the beneficiary to represent him or her in the appeal
• An attorney filing on behalf of a beneficiary
• A custodial parent or guardian of a beneficiary under 18 years of age

A network provider is never an appropriate appealing party unless the beneficiary has appointed the provider, in writing, to represent him or her for the purpose of the appeal. To avoid possible conflict of interest, an officer or employee of the United States—such as an employee or member of a uniformed service, including an employee or staff member of a uniformed services legal office, or a beneficiary counseling and assistance coordinator, subject to exceptions in Title 18, United States Code, Section 205—is not eligible to serve as a representative unless the beneficiary is an immediate family member.
               

Medical Necessity Determinations

Medical necessity determinations are based solely on medical necessity—whether, from a medical point of view, the care is appropriate, reasonable, and adequate for the beneficiary’s condition. Generally, determinations relating to health benefits are considered medical necessity determinations. There are expedited procedures for appealing decisions denying requests for prior authorization of services and requests for continued inpatient stays. If an expedited appeal is available, the initial and appeal denial decisions will fully explain how to file an expedited appeal.
               

Factual Determinations

Factual determinations involve issues other than medical necessity. Some examples of factual determinations include: coverage issues (i.e., determining whether the service is covered under TRICARE policy or regulation), all foreign claims determinations, and denial of a provider’s request for approval as a TRICARE-authorized provider.
         

Provider Sanction Determinations

Providers who request approval as TRICAREauthorized providers, but are denied approval by either TMA or Humana Military, may appeal those decisions and request a reconsideration. Provider sanction determinations occur when providers are expelled from TRICARE. Providers may be sanctioned by TRICARE because of failure to maintain credentials, provider fraud, abuse, conflict of interest, or other reasons. Only the provider or his or her representative can appeal. If the sanctions are appealed, an independent hearing officer will conduct a hearing administered by the TMA Appeals and Hearings Division.

Providers who are not eligible for authorization by TRICARE because of fraud and abuse against another federal or federally funded program or a state or local licensing authority (e.g., Medicare or Medicaid) may not appeal through the TRICARE system. Determination is the responsibility of the uniformed services.
          

Non-Appealable Issues

• POS determinations, with the exception of whether services were related to an emergency and therefore exempt from the requirement for referral and authorization
• Allowable charges (The TRICARE-allowable cost or charge for services or supplies is established by regulation.)
• A beneficiary’s eligibility, since this determination is the responsibility of the uniformed services
• Provider sanction (The provider is limited to exhausting administrative appeal rights.)
• Network provider/contractor disputes
• Denial of services from an unauthorized provider
• Denial of a treatment plan when an alternative treatment plan is selected
• Denial of services by a PCM

Waiver of Liability

Subject to application of other TRICARE definitions and criteria, the principle of waiver of liability is summarized as follows:

If the beneficiary did not know, or could not reasonably be expected to know, that certain services were potentially excludable from the basic TRICARE program by reason of being not medically necessary, not provided at an appropriate level, custodial care, or other reason relative to reasonableness, necessity, or appropriateness (hereafter, all such services will be referred to as not medically necessary), then the beneficiary will not be held liable for such services and, under certain circumstances, payment may be made for the excludable services as if the exclusion for such services did not apply.

The TRICARE beneficiary can be held financially responsible in the following instances:

• If both the non-network participating provider and the beneficiary knew the services were excluded
• If the beneficiary did not notify the non-network participating provider of having TRICARE coverage
• If the beneficiary knew the services were excluded but the non-network participating provider did not

Waiver of liability also does not apply to services provided by a network provider. Network providers may never bill beneficiaries for services denied for medical necessity or appropriateness. This requirement does not apply to TRICARE network pharmacies.

For a more detailed explanation of the reconsideration and appeals process, refer to Chapter 13 of the TRICARE Operations manual.

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