Appeal

An appeal is a formal request to have TRICARE reconsider a claim that was denied or a coverage decision you disagree with. The TRICARE appeals process provides beneficiaries with a structured way to challenge adverse decisions and seek resolution.

Types of appealable decisions: • Denied claims for services received • Prior authorization denials • Determination that a service is not medically necessary • Incorrect payment amounts • Benefit coverage disputes • Provider payment disputes

TRICARE appeals process: • Level 1 - Initial Reconsideration: Submit to your regional contractor within 90 days of the initial decision • Level 2 - Formal Review: If dissatisfied with Level 1, request a formal review within 60 days • Level 3 - Independent Hearing: For claims over a certain dollar amount, request an independent hearing

How to file an appeal: • Write a clear statement explaining why you disagree with the decision • Include your beneficiary information and claim details • Attach supporting medical documentation • Submit any additional evidence from your provider • Keep copies of everything submitted

Tips for successful appeals: • Include a letter from your treating provider supporting medical necessity • Reference specific TRICARE policy that supports your position • Submit all supporting documentation with the initial appeal • Respond to requests for additional information promptly • Track all deadlines throughout the process