Why Claims Get Denied
Understanding the reason for your denial is the first step toward a successful appeal:
Service Not Medically Necessary
TRICARE determined the treatment or procedure was not medically necessary based on their clinical guidelines.
Prior Authorization Not Obtained
The required prior authorization was not secured before the service was rendered.
Out-of-Network Provider Used (Prime)
You received care from a provider outside the TRICARE Prime network without a referral.
Timely Filing Deadline Missed
The claim was not submitted within 1 year from the date of service.
Coding Errors on the Claim
Incorrect diagnosis or procedure codes were submitted by the provider, causing the claim to be rejected.
Service Not Covered Under Your Plan
The specific service or treatment is not a covered benefit under your current TRICARE plan.
Missing or Incomplete Documentation
Required medical records, supporting documents, or claim information was missing or incomplete.
The TRICARE Appeals Process (Step-by-Step)
Follow these five steps to appeal a denied TRICARE claim:
Step 1: Review Your Explanation of Benefits (EOB)
- Look for the specific denial reason code and description on your EOB
- Note the date of service, claim number, and amount denied
- Check for any instructions on how to appeal the decision
- Find your EOB on the Express Scripts portal or your regional contractor portal
Step 2: Contact Your Regional Contractor
- Call the customer service number printed on your EOB
- Ask for a detailed explanation of why the claim was denied
- Request any specific documentation needed for the appeal
- East Region: Humana Military 1-800-444-5445
- West Region: Health Net Federal Services 1-844-866-9378
Step 3: File an Initial Appeal (First Level)
- Must be filed within 90 days of the initial decision
- Submit in writing with all supporting documentation
- Include: your name, SSN/DOD ID, claim number, date of service, and explanation of why you disagree
- Attach: provider notes, medical records, and letters of medical necessity
Step 4: Request Reconsideration (Second Level)
- If your first appeal is denied, you have 60 days to request reconsideration
- Submit your request to the regional contractor
- Include any new evidence or documentation not in the first appeal
- Your case will be reviewed by a different team than the initial appeal
Step 5: Independent External Review (Third Level)
- Final appeal level — heard by an independent review organization
- Must be requested within 60 days of the reconsideration decision
- For claims over $300: a formal hearing is available
- You may bring a representative or attorney to speak on your behalf
Important Timelines
Missing a deadline means losing your right to appeal. Keep track of these dates:
| Action | Deadline |
|---|---|
File initial appeal | Within 90 days of denial |
First-level decision issued | Within 60 days |
Request reconsideration | Within 60 days of first-level decision |
Reconsideration decision issued | Within 60 days |
Request external review | Within 60 days of reconsideration |
Total process duration | Up to 6–9 months |
All deadlines are calculated from the date on the decision letter, not the date you received it. If you received the letter late, note the postmark date as evidence.
Tips for a Successful Appeal
Increase your chances of overturning a denial:
- Always appeal in writing and keep copies of everything you send
- Include a letter from your doctor stating medical necessity
- Be specific about why the denial was incorrect — cite facts, not emotions
- Reference TRICARE policy manual chapters that support your case
- Keep a log of every phone call (date, time, name of representative)
- Request a Beneficiary Counseling and Assistance Coordinator (BCAC) for free help
Pro Tip: Send your appeal via certified mail so you have proof of delivery. Keep copies of every document you submit and every response you receive.
What to Include in Your Appeal Letter
Make sure your appeal includes all of the following for the best chance of success:
Important: Send your appeal via certified mail with return receipt requested so you have proof of delivery. Keep copies of everything you submit, and note the date you mailed it.
When to Get Professional Help
You don't have to navigate the appeals process alone. These resources can help:
TRICARE Beneficiary Counseling and Assistance Coordinators (BCACs)
Available at Military Treatment Facilities, BCACs help you understand benefits and navigate the appeals process at no cost.
Patient Advocates at Your MTF
Every military hospital has patient advocates who can help resolve billing disputes and guide you through filing complaints and appeals.
TRICARE Claims Attorneys
Attorneys specializing in TRICARE disputes can draft appeal letters, represent you at hearings, and handle complex cases. Many offer free initial consultations.
Healthcare Billing Advocates
Billing advocates review claims for errors, negotiate with contractors, and ensure your claims are coded and processed correctly.
Know Your Rights
As a TRICARE beneficiary, you are entitled to the following protections:
Right to Appeal Any Denial
You have the legal right to appeal any TRICARE claim denial, regardless of the denial reason or dollar amount.
Right to Independent Review
After exhausting internal appeals, you are entitled to have your case reviewed by an independent organization not affiliated with TRICARE or its contractors.
Right to Representation
At any stage of the appeals process, you can appoint a representative — including a BCAC, patient advocate, attorney, or family member — to act on your behalf.
Balance Billing Protection
TRICARE network providers are prohibited from billing you for amounts above the TRICARE-allowed charge. If a network provider balance bills you, report it to your regional contractor.
Common Questions About TRICARE Appeals
How long does a TRICARE appeal take?
Level 1 appeals are typically resolved within 60 days. Level 2 reconsiderations can take another 60 days. Level 3 external reviews may take several additional months. The entire process from initial appeal to final hearing can take 6 to 9 months.
Does filing a TRICARE appeal cost anything?
No. Filing a TRICARE appeal is completely free at all three levels. There is no fee to submit an initial appeal, request reconsideration, or participate in an external review. You only incur costs if you choose to hire an attorney or private advocate.
Can I continue treatment while my appeal is pending?
Yes, you can generally continue receiving treatment while your appeal is being processed. However, you may be responsible for paying out of pocket until the appeal is resolved. If the appeal is successful, you will be reimbursed for covered services.
What if my appeal is denied at all three levels?
If your appeal is denied at all three levels, you may still have options. You can contact your Congressional representative for assistance, file a complaint with the Defense Health Agency, or consult with a benefits attorney about additional legal remedies.
Where do I send my TRICARE appeal?
Send your appeal to your regional contractor. For the East Region, submit to Humana Military. For the West Region, submit to Health Net Federal Services. The exact mailing address and fax number will be listed on your Explanation of Benefits (EOB).