TRICARE Claim Appeals/Reconsiderations
In the event that you disagree with payment, TRICARE has a claim-appeals process to review your claim. There are a few different types of claim appeals:
Network provider claim appeals—Network providers who are dissatisfied with claim denial can appeal under the administrative review process. The process for administrative review and general claim appeals are similar and require the same information.
Non-network provider and beneficiary claim appeals—Non-network, participating providers (those who accept assignment) and beneficiaries can appeal a TRICARE claim.
Claim adjustments —Providers or beneficiaries can request allowable charge reviews if they disagree with the reimbursement allowed on a claim. This includes appeals for “By Report” or unlisted procedures where a provider can request an appeal.
Following are 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 promptly resolve 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 appeals process 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.
Claims Adjustments and Allowable Charge Reviews
An allowable charge review can be requested by a provider or beneficiary if either party disagrees with the reimbursement allowed on a claim. This includes “By Report” or unlisted procedures where a provider can request a review.
The following issues are considered reviewable:
- 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 lack of authorization
- POS when reason for dispute is other than emergency care
- Claims denied due to late filing
- Charges denied as a duplicate charge
- Claims denied as “Requested information was not received”
- Coding issues
- Claims denied because non-availability statement is not in DEERS
- Network provider disputes relating to contractual reimbursement amount
If requesting an allowable charge review, you
must submit the following information:
- A copy of the claim and the TRICARE EOB or TRICARE Summary Payment Voucher/Remit
- Supporting medical records and any new information that was not originally submitted with the claim
Note: Requests must be postmarked or received
within 90 calendar days of the date of the TRICARE EOB.
Send all requests to:
TRICARE South Region Customer Service Department
P.O. Box 7032
Camden, SC 29020-7032
Appeals and Administrative Reviews of Claim Denials
The following are considered appealable issues:
- 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 service was for emergency care
Note: Network providers must hold the beneficiary harmless for non-covered care. Under the “hold-harmless” policy, the beneficiary has no financial liability and, therefore, has no appeal rights. However, if the beneficiary has waived his or her hold-harmless rights, the beneficiary may be financially liable and may have further appeal rights.
Appeal and administrative review 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 U.S. Postal Service. If the postmark on the envelope is not legible, the date of receipt is deemed to be the date of the filing.
Mail requests to:
TRICARE South Region Appeals Department
P.O. Box 202002
Florence, SC 29502-2002
After your request is submitted, Humana Military will notify you of the outcome in writing or by telephone. For more detailed information about the appeals process, visit the Claims Appeals/Reconsiderations web page.
When filing appeals, keep in mind the following:
- All appeal/administrative review requests must be signed and in writing.
- 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.
- Additionally, provide the following information with your appeal:
- Sponsor’s SSN
- Beneficiary’s/patient’s 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. Persons or providers who may appeal are limited to:
- TRICARE beneficiaries (including minors)
- Participating, non-network, TRICARE-authorized providers
- A custodial parent or guardian of a minor beneficiary
- A provider denied approval as a TRICARE-authorized provider
- A provider who has been terminated, excluded, or suspended
- A representative appointed by a proper appealing party. Examples of representatives are:
- Parents of a minor*
- An attorney
- A network provider
- Administrative reviews must be requested by the network provider.
* If your patient is a minor, his or her custodial parent is presumed to have been appointed his or her representative in the appeal.
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