Federal agency ยท TRICARE (Defense Health Agency)
TRICARE appeals
The official TRICARE page on the four kinds of appeal (factual, medical necessity, pharmacy, and Medicare-TRICARE), with mailing addresses for each regional contractor and the Defense Health Agency.
Know before you go
The kind of appeal depends on the issue: a payment denial is a factual appeal, a denied pre-authorization is a medical necessity appeal. For a factual appeal the page says the postmark must be within 90 days of the date on the explanation of benefits or decision; check the date on your notice, which controls. Small amounts get limited review: the page says a decision on less than $50 is final. Your denial letter gives the exact filing instructions.
- Cost
- Not stated. The page lists no fee.
- Where
- Nationwide
- How to start
- Read your denial letter to see which kind of appeal it describes, then send a letter with a copy of the decision to your contractor's appeals address on the page.
- Have ready
- Your explanation of benefits or decision letter; Supporting medical records; Your sponsor's information and TRICARE region
Where this comes from
- Provider
- TRICARE (Defense Health Agency)
- Source we read
- https://www.tricare.mil/Appeals
- Date we read it
- . This is not a fresh check.
- Date the provider printed
- Not displayed
- What we checked
- We read the provider's public page. We have not verified availability, eligibility or outcomes for any individual.
Other starting points
- Program or service
Beneficiary and Family Centered Care Quality Improvement Organizations: find yours
The Medicare contractors that handle fast appeals when hospital or other care is ending too soon, and complaints about the quality of care. Each state is assigned to one of two organizations.
From Centers for Medicare & Medicaid Services
- Program or service
California Department of Managed Health Care: Independent Medical Review
California's regulator for managed care plans reviews denials of medical services, emergency payment and experimental treatment through Independent Medical Review. One form starts either a review or a consumer complaint.
From California Department of Managed Health Care
- Program or service
Center for Medicare Advocacy self-help materials
Downloadable self-help toolkits for Medicare denials involving home health care, outpatient therapy and skilled nursing facility care, from a nonprofit law organization. The page describes materials, not a helpline.
From Center for Medicare Advocacy