Filing an Appeal
You can appeal certain decisions made by the Defense Health Agency or your contractor about your benefit. There are specific benefit issues that are appealable and the appeal process varies depending on the type of benefit issue:
Requirements for Filing an Appeal
1. An appropriate party must submit the appeal:
- You, the beneficiary
- Your custodial parent (if you are a minor) or your guardian
- A person appointed in writing, by you, to represent you for the purpose of the appeal
- An attorney filing on your behalf
- Non-network participating providers
If a physician or other party is going to submit the appeal, you must complete an Appointment of Representative and Authorization to Disclose Information form or an Authorization to Release Information form. If the appeal is submitted without this form, it won't be processed.
Note: Network providers are not appropriate appealing parties,unless appointed by you in writing.
2. The appeal must be in writing.
An appeal must be filed within 90 days of the date on the explanation of benefits or denial notification letter and mailed to the appropriate address.
||Health Net Federal Services, LLC
c/o PGBA LLC/TRICARE Claims Appeals
P.O. Box 870148
Surfside Beach, SC 29587-9748
||TRICARE South Region Appeals
P.O. Box 202002
Florence, SC 29502-2002
||TRICARE West Region
P.O. Box 105493
Atlanta, GA 30348-5493
||International SOS Assistance, Inc.
P.O. Box 11570
Philadelphia, PA 19116 USA
|TRICARE For Life (U.S. & Territories)
||WPS-TRICARE For Life
P.O. Box 7490
Madison, WI 53707-7490
||Express Scripts, Inc.
P.O. Box 60903
Phoenix, AZ 85082-0903
3. The issue must be an appealable issue.
The following are non-appealable issues:
- Allowable charges
- Denial of services from an unauthorized provider
- Denial of treatment plan when an alternative treatment plan is selected
- Refusal by a primary care manager to provide services or refer a beneficiary to a specialist
- Point of service issues, except for whether the services were related to an emergency
For these non-appealable issues, TRICARE provides a grievance process that allows you to submit in writing your concern or complaint.
4. There must be an amount in dispute to file an appeal.
- If appealing the denial of an authorization in advance of receiving the actual services, the amount in dispute is the estimated TRICARE allowable charge for the services requested.
- There is no minimum amount in dispute necessary to request reconsideration.