Appeals

The appeal process is only applicable to denials for services determined to be a non-covered benefit, or not medically necessary, and is only accepted from appropriate appealing parties.

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 PGBA.

TRICARE Operations Manual (TOM) - Ch. 12 Sec. 3

Allow charge submissions:

Customer Service
Humana Military
PO Box 202146
Florence, SC 29502-2146

Fax: (877) 489-0011

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

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 

TRICARE Operation Manual (TOM) - Ch. 12 Sec. 3

Claims reconsideration submissions:

Humana Military Claims
ATTN: Reconsideration request
PO Box 202146
Florence, SC 29502-2146

Fax: (877) 489-0011

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

Reconsideration FAQs