Appeals & grievances

Appealing a decision

If you believe a service or claim was improperly denied, in whole or in part, you (or another appropriate party) may file an appeal.

What can you appeal?

  • An appeal must involve an appealable issue. For example, you have the right to appeal TRICARE decisions regarding the payment of your claims.
  • You also may appeal the denial of a requested authorization of services even though no care has been provided and no claim submitted.

What cannot be appealed?

  • There are some things you may not appeal. For example, you may not appeal the denial of a service provided by a healthcare provider not eligible for TRICARE certification.
Note: When services are denied based on a medical necessity or a benefit decision, you are notified automatically in writing. The notification will include an explanation of what was denied or why a payment was reduced and the reasoning behind that decision. Your appeal must meet the requirements listed in the Prime handbook.

Need to file an appeal?

  • Appeals must be filed with Humana Military within particular deadlines. Prior authorization denial appeals may be either expedited or non-expedited, depending on the urgency of the situation.
  • You or an appointed representative must file an expedited review of a prior authorization denial within three calendar days after receipt of the initial denial.
  • A non-expedited review of a denial must be filed no later than 90 days after receipt of the initial denial.
  • For specific information about filing an appeal in your region, contact Humana Military at 1-800-444-5445.

Note: If you are a beneficiary choosing to appoint a representative to appeal a claim on your behalf, you will need to complete the appointment of representative form.

Information required for appeals:

  • Beneficiary’s name, address and telephone number
  • Sponsor’s Social Security number (SSN)
  • Beneficiary’s date of birth
  • Beneficiary’s or appealing party’s signature
A description of the issue or concern must include:
  • The specific issue in dispute
  • A copy of the previous denial determination notice
  • Any appropriate supporting documents

Send your appeal to:

Claims appeals:
TRICARE South Region Appeals
P.O. Box 202002
Florence, SC 29502-2002

Prior authorization appeals:

Humana Military
P.O. Box 740044
Louisville, KY 40201-7444

Behavioral health appeals:

ValueOptions Federal Services
Attn: Appeals and Reconsideration Department
P.O. Box 551138
Jacksonville, FL 32255-1138
Note: If you are not satisfied with a decision rendered on an appeal, there are further levels of appeal.

Filing a grievance

A grievance is a written complaint or concern about a non-appealable issue regarding a perceived failure by any member of the healthcare delivery team—including TRICARE authorized providers, military providers, regional contractors or subcontractor personnel—to provide appropriate and timely healthcare services, access or quality, or to deliver the proper level of care or service. The grievance process allows full opportunity to report in writing any concern or complaint regarding healthcare quality or service. Any TRICARE civilian or military provider, TRICARE beneficiary, sponsor, parent or guardian, or other representative of an eligible dependent child may file a grievance. Humana Military is responsible for the investigation and resolution of all grievances. Grievances are resolved no later than 60 days from receipt. Following resolution, the party who submitted the grievance will be notified of the review completion.

Grievances may include such issues as:

  • The quality of healthcare or services aspects like accessibility, appropriateness, level, continuity or timeliness of care
  • The demeanor or behavior of providers and their staff
  • The performance of any part of the healthcare delivery system
  • Practices related to patient safety

Information required for filing a grievance:

  • The beneficiary’s name, address and telephone number
  • Sponsor’s SSN
  • Beneficiary’s date of birth
  • Beneficiary’s signature
  • A description of the issue or concern must include:
    • Date and time of the event
    • Name of the provider(s) and/or person(s) involved
    • Location of the event (address)
    • The nature of the concern or complaint
    • Details describing the event or issue
    • Any appropriate supporting documents

To file your grievance with Humana Military, submit your grievance in writing to:

Regional Grievance Coordinator
Humana Military Healthcare Services
8123 Datapoint Drive Suite 400
San Antonio, TX 78229

For behavioral healthcare concerns, send your information to:

Grievance Department
ValueOptions Federal Services
P.O. Box 551188
Jacksonville, FL 32255-1188