Prepayment Review and TRICARE Claim Appeals/Reconsiderations
Prepayment Review
Prepayment review of medical necessity or appropriate level of care is reviewed by Humana Military upon written request. You may request reconsideration of a review within 90 days of the initial claim determination by PGBA at the following address:
TRICARE South Region
Appeals Department
P.O. Box 202002
Florence, SC 29502-2002
TRICARE Claim Appeals/Reconsiderations
TRICARE has created a claim appeals process to review your claim in the event you disagree with payment. There are a few different types of claim appeals:
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Network provider claim appeals: Network providers who are dissatisfied with the denial of a claim can appeal under the administrative review process. The process for administrative review and general claim appeals are similar and require the same information to process your request.
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Non-network provider and beneficiary claim appeals: Non-network, participating providers (those who accept assignment) and beneficiaries can appeal a TRICARE claim.
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Claim adjustments: An allowable charge review can be requested by a provider or beneficiary if either party disagrees with reimbursement allowed on a claim. This includes appeals for “By Report” or unlisted procedures where a provider can request an appeal.
Refer to Figures 8.9 and 8.10 for details about the appropriate types of appeal requests, time frames for submitting an appeal request, addresses, and the information to include with the request. By following the rules and timelines for requesting reviews, you can help to achieve prompt resolution to your request.
After your request is submitted, Humana Military will notify you in writing or by telephone of the outcome. You can also obtain more detailed information about the various levels of appeals through the Claims Appeals/Reconsiderations web page.
Section 1869/1878 Social Security Act-Appeals Determination
There shall be no administrative or judicial review under section 1869, 1878, or otherwise, of the classification system, the relative weights, payment amounts, and the geographic adjustment factor, if any, under this subparagraph.
Figure 8.9 Requirements for Claims Adjustments and Allowable Charge Reviews
| Reviewable Issues |
Time Frames |
Contact Information |
- Allowable charge complaints
- Charges denied as “Included in a paid service”
- Keying errors/Corrected bills
- Eligibility denials/patient not in DEERS
- Cost-share and deductible inquiries/disputes
- Claims denied because the provider is not a TRICARE-authorized provider
- ClaimCheck denials (except assistant surgeons)
- OHI denials/issues
- Prescription drug coverage
- Third-party liability denials/issues
- Claims denied or payments reduced due to no authorization
- POS when reason for dispute is other than emergency care
- Claims denied because they were filed late
- Charges denied as a duplicate charge
- Claims denied as “Requested information was not received”
- Coding issues
- Claims denied because nonavailability statement is not in DEERS
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Requests must be postmarked or received within 90 calendar days of the date of the TRICARE EOB. |
TRICARE Correspondence:
TRICARE South Region
Customer Service Department
P.O. Box 7032
Camden, SC 29020-7032 |
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If requesting an allowable charge review, the following information will be needed:
- A copy of the claim and the TRICARE EOB or Summary Payment Voucher
- Supporting medical records and any new information that was not originally submitted with the claim
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Figure 8.10 Requirements for Claims Adjustments and Allowable Charge Reviews
| 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 POS only when the reason for dispute is that the care was emergency
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- Requests must be postmarked or received within 90 calendar days of the date of 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.
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TRICARE Correspondence:
TRICARE South Region
Appeals Department
P.O. Box 202002
Florence, SC 29502-2002 |
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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 SSN
- 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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