What is a factual appeal?
You can file a factual appeal when TRICARE:
- Denies payment for services or supplies you received
- Stops payment for services or supplies that were previously authorized
To File a Factual Appeal:
Send a letter to your contractor's address. Make sure the postmark is within 90 days of the date on the explanation of benefits (EOB) or other decision.
- Include a copy of the EOB or other decision.
- Include any supporting documents.
- If you don’t have all the supporting documents, send the appeal with what you have. Make sure to state that you’ll send more information soon.
Your contractor will review your appeal and send you an appeal decision.
- If the amount you're appealing is less than $50, the decision is final.
- If the amount is $50 or more and the letter says the Defense Health Agency is the next level of appeal, you can request a formal review.
To Request a Formal Review:
- Send a letter to the Defense Health Agency. Make sure the postmark is within 60 days of the date on the appeal decision.
- Include copies of the decision, and any supporting documents.
The Defense Health Agency reviews and issues a formal review decision.
- If the disputed amount is less than $300, the decision is final.
- If the disputed amount is $300 or more, you can request an independent hearing.
To Request an Independent Hearing:
- Send a hearing request to the Defense Health Agency. Make sure the postmark is within 60 days of the date of the formal review decision.
- Include a copy of the formal review decision.
- Include any supporting documents you haven’t submitted before.
The independent hearing takes place at a location convenient to both the requesting party and the government.
- An independent hearing officer issues a recommended decision.
- The final decision is issued by the Defense Health Agency director (or designee) or the Assistant Secretary of Defense for Health Affairs.