Coverage type · Military, veteran or federal employee
TRICARE
Military health coverage. Your first appeal is a written reconsideration, mailed within 90 days of the date on your Explanation of Benefits. The next steps depend on whether the denial is about the facts or about medical necessity.
On this page 7
- Who has this
- Service members, retirees, and family members who get health coverage through TRICARE, the military health program.
- Who regulates it
- The Defense Health Agency, working through regional contractors. The appeal rules are in section 199.10 of Title 32 of the Code of Federal Regulations.
- Can your state help?
- No. The appeal steps are federal and run through TRICARE. No state agency is part of them. Find your state.
How to tell this is your coverage
- Your denial comes on a TRICARE Explanation of Benefits or another written TRICARE decision, from a regional contractor.
- Your region's contractor in 2026: East Region, Humana Military; West Region, TriWest Healthcare Alliance; Overseas, International SOS. TRICARE For Life, which wraps around Medicare, is handled by Wisconsin Physicians Service. Pharmacy is handled by Express Scripts.
- If you also have Medicare and Medicare denied a service that both programs cover, the appeal goes to Medicare first.
The appeal steps, in order
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First appeal
Official name: Reconsideration
- Who decides
- The TRICARE contractor that decided your claim
- Your deadline
- In writing, mailed (postmarked) within 90 days of the date on the Explanation of Benefits or other decision. Pharmacy denials are appealed to Express Scripts within 90 days of the decision. Check the date on your notice, which controls.
- Their deadline
- The contractor normally decides within 60 days.
- What to send
- A written request mailed in time. Say which decision you dispute and why. Add your medical records and a letter from your doctor. A provider that does not take TRICARE payment on the claim (a nonparticipating provider) cannot appeal; you can.
- If you lose, or hear nothing
- If the contractor upholds a decision about the facts (for example, coverage or eligibility), ask the Defense Health Agency for a formal review. If the denial was for medical necessity, ask for a second reconsideration.
- The rule
- 32 CFR 199.10, appeal and hearing procedures
-
Second level
Official name: Formal review (factual denials) or second reconsideration (medical necessity denials)
- Who decides
- For factual denials, the Defense Health Agency. For medical necessity denials, the TRICARE Quality Monitoring Contractor.
- Your deadline
- Factual denials: mail your request within 60 days of the reconsideration decision, and only if the amount in dispute is $50 or more. Medical necessity denials: request within 90 days of the contractor's decision. Check the date on your notice, which controls.
- Their deadline
- The formal review decision is normally issued within 90 days. The second reconsideration time is not stated in the rules we use.
- What to send
- A written request with the reconsideration decision and your evidence. The amount in dispute is what TRICARE would pay if the service were covered. Under listed conditions you can combine claims to reach the amount.
- If you lose, or hear nothing
- If you still disagree and enough money is in dispute, you can ask for an independent hearing.
- The rule
- TRICARE, appeals
-
Independent hearing
Official name: Hearing before a hearing officer
- Who decides
- A hearing officer issues a recommended decision. The Director of the Defense Health Agency (or a designee), or the Assistant Secretary of Defense for Health Affairs, issues the final decision.
- Your deadline
- Mail your request within 60 days of the formal review decision or the second reconsideration decision. The amount in dispute must be $300 or more. Check the date on your notice, which controls.
- Their deadline
- The rules we use do not state a decision deadline at this level.
- What to send
- A written request for a hearing with the earlier decisions and your evidence. You may want a lawyer or free legal aid at this level.
- If you lose, or hear nothing
- This is the final level.
- The rule
- 32 CFR 199.10, hearing procedures
If waiting could harm your health
TRICARE has an expedited appeal only for medical necessity denials of a continued inpatient stay or of pre-authorization. TRICARE's regional contractors state the deadline as within 3 calendar days of receiving the denial. We could not find the regulation behind that deadline, and the time the contractor has to decide an expedited appeal is not confirmed, so call your regional contractor right away and ask. Check the date on your notice, which controls.
Free help for this coverage
- TRICARE appeals page
The official description of each level and where to send it.
- East Region contractor, Humana Military
Call 800-444-5445 (2026 East Region contractor).
- West Region contractor, TriWest Healthcare Alliance
Call 888-874-9378 (2026 West Region contractor).
- Other TRICARE contractors
Overseas is International SOS. TRICARE For Life, which wraps around Medicare, is Wisconsin Physicians Service. Pharmacy is Express Scripts. Which region you are in is on the TRICARE regions page; the list of states that moved from the East Region to the West Region is not confirmed.
- Legal aid
Free civil legal help for people with low incomes. A program can advise you on an appeal, but it cannot take every case. Your state page lists legal aid programs for your state.
Who this covers
This page is for people covered by TRICARE, the military health program. If you have both Medicare and TRICARE, the order of appeals matters; see below. Read the TRICARE appeals guide.
How to tell this is your coverage
The decision comes from TRICARE or its regional contractor, on an Explanation of Benefits or other written decision. Contractors in 2026 are listed under “How to tell” above. The contract start dates are not confirmed.
What does not apply to you
TRICARE appeals do not work like Medicare appeals. The deadlines are 90 days, then 60 or 90 days, and the dollar thresholds are fixed in the regulation at $50 and $300. They are not adjusted each year. The thresholds apply to factual denials and to the independent hearing, not to every step.
When Medicare denies a service that both programs cover, appeal to Medicare first. TRICARE appeal rights apply only when the service is payable by TRICARE and not by Medicare.
Where people go wrong
- Assuming your doctor can appeal. A provider that does not take TRICARE payment on the claim is not a party to the decision and cannot appeal. You can.
- Using the wrong second step. A factual denial goes to formal review (with a $50 minimum). A medical necessity denial goes to a second reconsideration (90 days), not to formal review.
- Waiting on a pre-authorization or inpatient stay denial. The expedited route is only for those two kinds of medical necessity denials, and its deadline is stated as 3 calendar days.
- Mailing on the last day without a postmark. Both the 90-day and 60-day clocks run on the mailing date, so keep proof of when you sent it.
Free help is listed above.