Appealing a decision

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:

Humana Military
Attn: Utilization Management
P.O. Box 740044
Louisville, KY 40201-9973

Fax: (877) 850-1046

Medical necessity determinations

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

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.

Proper appealing parties

  • A TRICARE beneficiary (including minors)
  • A non-network participating provider
  • A provider who has been denied approval as a TRICARE-authorized provider or who has been terminated, excluded, suspended or otherwise sanctioned
  • A person who has been appointed in writing by the beneficiary to represent him or her in the appeal
  • An attorney filing on behalf of a beneficiary
  • A custodial parent or guardian of a beneficiary under 18 years of age

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.

Non-appealable issues notifications

Certain issues are considered non-appealable. Non-appealable issues include the following:

  • POS determinations, with the exception of whether services were related to an emergency and are, therefore, exempt from the requirement for referral and authorization
  • Allowable charges (TRICARE allowable charge for services or supplies)
  • A beneficiary’s eligibility (determination is the responsibility of the uniformed services)
  • Provider sanction (provider is limited to exhausting administrative appeal rights)
  • Network provider/contractor disputes
  • Denial of services from an unauthorized provider
  • Denial of a treatment plan when an alternative plan is selected
  • Denial of services by a PCM