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 appeal requests. The appeal process is only applicable to charges denied as not covered or not medically necessary and are only accepted from appropriate appealing parties.
Note: Network providers are not proper appealing parties.
Providers can submit a request for an administrative review when there are concerns about how a claim processed. This process is separate from the appeals process.
The following are common reasons a provider may submit a request for administrative review, including:
TRICARE East Region claims
P.O. Box 8904
Madison, WI 53707-8923
Fax: (608) 221-7536
Network providers are not a proper appealing party, but can appeal on behalf of the beneficiary with a signed Appointment of representation form from the beneficiary.
Claims that are denied by TRICARE due to medical necessity or a factual determination that a service is excluded by law or regulation are subject to the appeal process. The Explanation of Benefits (EOB) or provider remittance will indicate if a denied charge is appealable. If the EOB or remittance does not state the denied charge is appealable, the provider may request an allowable charge review instead.
The following are considered appealable issues:
Note: Network providers must hold the beneficiary harmless for non-covered care. Under the hold-harmless policy, the beneficiary has no financial liability and, therefore, has no appeal rights. However, if the beneficiary has waived his or her hold-harmless rights, the beneficiary may be financially liable and may have further appeal rights.
To submit an appeal on behalf of a beneficiary, a signed Appointment of representative form must accompany the appeal. Appeal requests must be postmarked or received within 90 calendar days of the date of the denial. For TRICARE purposes, a postmark is a cancellation mark issued by the US Postal Service. If the postmark on the envelope is not legible, the date of receipt is deemed to be the date of the filing.
After a request is submitted, Humana Military will notify the appealing party in writing or by telephone of the outcome.
An appropriate appealing party must request appeals. Persons or providers who may appeal are limited to:
Examples of representatives are:
Note: A completed Appointment of representative form must be on file when representative is submitting an appeal on behalf of the proper appealing party.
When filing appeals, keep in mind the following:
In addition, include the following information with an appeal:
Humana Military/TRICARE East appeals
PO Box 740044
Louisville, KY 40201-7444