TRICARE provider with beneficiary

Appeals & grievances

If you believe a service or claim was improperly denied, in whole or in part, you may file an appeal. 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. The grievance process allows full opportunity to report in writing any concern or complaint regarding healthcare quality or service.

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.

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. If you are not satisfied with the decision rendered on an appeal, there are further levels of appeal.

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

Where should you send your appeals?

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

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, demeanor or behavior of providers and their staff, performance of any part of the healthcare delivery system, or practices related to patient safety.

Information required for filing a grievance:

  • A description of the issue or concern must include:
    1. Date, time and location (address)of the event
    2. Name of the provider(s) and/or person(s) involved
    3. The nature of the concern or complaint
    4. Details describing the event or issue
    5. Any appropriate supporting documents
  • The beneficiary’s name, address and telephone number
  • Sponsor’s Social Security Number (SSN)
  • Beneficiary’s date of birth

Where should you send your grievances?

Humana Military Grievances
8123 Datapoint Drive, Suite 400
San Antonio, TX 78229