Appeals of claims denials

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 following are considered appealable issues:

  • Claims denied because the service is not covered under TRICARE or policy limitations
  • Claims denied as not medically necessary
  • Claims processed as Point of Service (POS) only when the reason for dispute is that the service was for emergency care

The following issues are not considered appeals:

  • Disagreeing with TRICARE laws and regulations
  • Disagreeing with the allowed amount for a particular service (see Allowable charge reviews)
  • Requests for additional information necessary to process a claim

Note: Network providers must hold the beneficiary harmless for noncovered 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. Appeal and administrative review 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:

  • TRICARE beneficiaries (including minors)
  • Participating non-network TRICARE-authorized providers
  • A custodial parent or guardian of a minor beneficiary
  • A provider denied approval as a TRICARE-authorized provider
  • A provider who has been terminated, excluded or suspended
  • A representative appointed by a proper appealing party

Examples of representatives are:

  • Parents of a minor (If the patient is a minor, his or her custodial parent is presumed to have been appointed his or her representative in the appeal.)
  • An attorney
  • A network provider

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:

  • All appeal requests must be in writing and signed by the appealing party or the appealing party’s representative
  • All appeal requests must state the issue in dispute
  • Be certain to include a copy of the initial denial (EOB/provider remittance advice) and any additional documentation in support of the appeal
  • If submitting supporting documentation, the timely filing of the appeal should not be delayed while gathering the documentation
  • If intending to obtain supporting documentation that is not readily available, file the appeal and state in the appeal letter the intention to submit additional documentation and the estimated date of submission
  • Proper appealing parties must meet the 90-day filing deadline, or the request for appeal will generally not be accepted

In addition, include the following information with an appeal:

  • Sponsor’s SSN or beneficiary’s DBN
  • Beneficiary’s name
  • Date(s) of service
  • Provider’s address, telephone/fax numbers and email address, if available
  • Statement of the facts of the request

Proper appealing parties may submit appeal requests to the following address:

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

Network providers may submit requests for administrative reviews at the following address:

TRICARE East Region Claims
P.O. Box 8904
Madison, WI 53707-8923

TRICARE claims information