You can file a factual appeal when TRICARE:
- Denies payment for services or supplies received
- Terminates payment for services or supplies that were previously authorized
When filing an appeal, keep copies of everything.
Filing Your Appeal
- Send a letter to the contractor's address specified in the notice of the right to appeal listed on your explanation of benefits (EOB) or other decision
- It must postmarked or received within 90 days of the date on the EOB or other decision
- Include a copy of the EOB or other decision along with any documents
- If you can't get all the supporting documents in time, send the appeal and state that you'll be sending additional information soon
If the amount you're appealing is less than $50, the contractor's decision is final. If the amount is more than $50 and the letter identifies the Defense Health Agency as the next level of appeal, you can request a formal review.
Requesting a Formal Review
- Send a letter to the Defense Health Agency
- It must be postmarked or received within 60 days of the date on the initial determination or reconsideration decision
- Include copies of the decision along with additional supporting documents
- The Defense Health Agency will issue a formal review decision
If the disputed amount is less than $300, the Defense Health Agency's decision is final. If the disputed amount is more than $300, you can request an independent hearing.
Requesting an Independent Hearing
- Send a hearing request to the Defense Health Agency
- It must be postmarked or recieved within 60 days of the date of the appeal decision
- Include a copy of the formal review decision being appealed and any supporting documents not previously submitted
An independent hearing officer will conduct the hearing at a location convenient to both the requesting party and the government. The hearing officer will issue a recommended decision and the Defense Health Agency director (or designee) or the Assistant Secretary of Defense for Health Affairs will issue the final decision.