TRICARE beneficiaries have the right to appeal decisions made by DHA or Humana Military. All initial and appeal denials explain how, where and by when to file the next level of appeal.
Prior authorization appeals:
Attn: Utilization Management
P.O. Box 740044
Louisville, KY 40201-9973
Fax: (877) 850-1046
Medical necessity determinations are based on whether the suggested care is appropriate, reasonable and adequate for the beneficiary’s condition. If an expedited appeal is available, the initial and appeal denial decisions will fully explain how to file an expedited appeal.
Factual determinations involve issues other than medical necessity. Some examples of factual determinations include coverage issues (i.e., determining whether the service is covered under TRICARE policy or regulation), all foreign claims determinations and denial of a provider’s request for approval as a TRICARE-authorized provider.
A network provider is never an appropriate appealing party unless the beneficiary has appointed the provider, in writing, to represent him or her for the purpose of the appeal. To avoid a possible conflict of interest, an officer or employee of the US government is not eligible to serve as a representative unless the beneficiary is an immediate family member.
Certain issues are considered non-appealable. Non-appealable issues include the following: