Claims adjustments and allowable charge reviews

A provider or a beneficiary can request an allowable charge review if either party disagrees with the reimbursement allowed on a claim.

This includes “by report” or unlisted procedures where a provider can request a review. The following issues are considered reviewable:

  • Allowable charge complaints
  • Charges denied as “included in a paid service”
  • Keying errors/Corrected bills
  • Eligibility denials/Beneficiary not in DEERS
  • Cost-share and deductible inquiries/disputes
  • Claims denied because the provider is not a TRICARE-authorized provider
  • Claims auditing tool denials (except assistant surgeons)
  • OHI denials/issues
  • Prescription drug coverage
  • Third-party liability denials/issues
  • Claims denied or payments reduced due to lack of authorization
  • Point Of Service (POS) when reason for dispute is other than emergency care
  • Claims denied due to late filing
  • Charges denied as a duplicate charge
  • Claims denied as “Requested information was not received”
  • Coding issues
  • Claims denied because Nonavailability Statement (NAS) is not in DEERS
  • Network provider disputes relating to contractual reimbursement amount

If requesting an allowable charge review, providers must submit the following information :

  • A copy of the claim and the TRICARE EOB or TRICARE summary
  • Payment voucher/remit
  • Supporting medical records and any new information

TRICARE claims information