What can be appealed?

• Authorization or claim denied as a non-covered benefit
• Authorization or claim denied as not medically necessary
• Point of Service (POS) charges can only be appealed when due to an emergency

A proper appealing party is:

• The patient, any age
• The parent or guardian of a patient under age 18 (except sensitive diagnosis claims)
• Non-network participating provider of services (cannot submit an expedited appeal)
• A provider that has been denied approval as an authorized TRICARE provider or who has been terminated, excluded, suspended or otherwise sanctioned
• The legal representative of the estate of a deceased beneficiary
• An attorney acting on behalf if an otherwise proper appealing party listed above
• The patient may appoint a representative.

Note: A completed Appointment of Representative (AOR) form must be submitted with the appeal request.