Appeals

The appeal process is only applicable to charges denied as not covered or not medically necessary and are only accepted from appropriate appealing parties.

A proper appealing party is:

  • The patient, any age.
  • The parent or guardian of a patient under age 18 (except sensitive diagnosis claims).
  • The patient may appoint a representative.

Note: A completed Appointment of Appeal Representative (AOR) form must be submitted with the appeal request. Appointed representatives MAY include:

  • Network providers; but, network providers cannot appeal without an AOR specific to the appeal being requested
  • The legal representative of the estate of a deceased beneficiary
  • An attorney acting on behalf of an otherwise proper appealing party listed above

Who cannot appeal:

  • Congressional Appeal Offices
  • Non-participating providers - Does not agree to accept the TRICARE-allowable amount
  • Health Benefit Advisors (HBA)
  • Beneficiary Service Representatives (BSR)
  • Network providers (unless an AOR form is on file indicating beneficiary has given permission for the provider to act on his/her behalf)

Learn how to file an appeal with Humana Military

 

Appeals submissions:

HMHSRECON@humana.com (Preferred method)
Fax: (877) 850-1046

Humana Military Appeals
PO Box 740044
Louisville, KY 40201-7444

Appeal submission process FAQs

 

Allowable charge review

If a provider or a beneficiary has concerns about how a claim processed, an administrative review, also known as an allowable charge review, can be requested. It’s important to differentiate allowable charge reviews from medical necessity denial appeal requests.

Providers can submit a request for an administrative review when there are concerns about how a claim processed. The following are common reasons a provider may submit a request for administrative review: a request for administrative review, including:

  • Allowed amount disputes
  • Charges denied due to requested information not received
  • Coding issues
  • Cost-share and deductible issues
  • Eligibility denials
  • Other Health Insurance (OHI) issues
  • Penalties for no authorization
  • Third Party Liability (TPL) issues
  • Timely filing limit denials
  • Wrong procedure code

Allowable charge appeals are processed by WPS.

Allow charge submissions:

Customer Service
TRICARE East Region
PO Box 8923
Madison, WI 53708-8923

Hours of operation: 8 AM to 7 PM ET
Phone: (800) 444-5445
Fax: (608) 221-7536

 

Claims reconsideration

Participating providers may have claims reconsidered through medical review for issues including:

  • Requests for verification that the edit was appropriately entered for the claim
  • Situations in which the provider submits documentation substantiating unusual circumstances existed 

Claims reconsideration submissions:

Customer Service
TRICARE East Region
PO Box 8923
Madison, WI 53708-8923

Hours of operation: 8 AM to 7 PM ET
Phone: (800) 444-5445
Fax: (608) 221-7536

Reconsideration FAQs

Supporting documentation instructions

 

Electronic submissions

To ensure your electronic submission is processed in a timely manner, please confirm you are submitting the information in the correct portal, inbox or web form. To avoid additional delays, please only include details on a single beneficiary and to not combine requests.

 

Fax or mail submissions

TRICARE may ask for additional details, including for you to use the letter you received again as the coversheet for the information that you return. The letters, utilized as a coversheet, allow Humana Military to quickly document and identify beneficiaries via barcode and OCR recognition, speeding up the process.

To ensure your documentation is processed quickly, please send a single correspondence or fax with information regarding a single beneficiary. If multiple pieces of correspondence are mailed at the same time, they must be divided with coversheets.

Humana Military accepts HIPAA-compliant electronic faxes sent using HIPPA-compliant companies, such as UpDox, Faxage or SRFax, among others available through a web search.