Bread Crumbs

Medical Necessity Appeals

  • You may file a medical necessity appeal when TRICARE denies prior authorization for requested services or supplies. 

To appeal a medical necessity decision, follow one of two processes: expedited or non-expedited. 

  • Most appeals are non-expedited  
  • Expedited appeals are only to reconsider approval of inpatient stays or prior authorization of services
  • The denial decision will explain how to file an expedited appeal  
  • Keep copies of everything

Filing a Non-Expedited 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 be 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 that support your position
  • If you can't get all the supporting documents in time, send the appeal and state that you'll be sending additional information soon

The contractor will review your case and issue a reconsideration decision. If you disagree with the reconsideration decision, you can appeal to the national quality monitoring contractor.

Getting a Second Reconsideration

  • Send a letter to the national quality monitoring contractor at the address specified in the reconsideration decision
  • It must be postmarked or received within 90 days of the date on the reconsideration decision
  • Include a copy of the reconsideration decision and any supporting documents

The national quality monitoring contractor will review the case and issue a second reconsideration decision.  If the amount in dispute is less than $300, the national quality monitoring contractor's decision is final.  If you're disputing $300 or more, you can request the Defense Health Agency to schedule an independent hearing.

Last Updated 7/14/2014

contact Your Contacts
Send appeals and appeals correspondence to:

Defense Health Agency
Appeals, Hearings and Claims Collection Division
16401 E. Centretech Parkway
Aurora, CO 80011-9066

View More Contacts

Downloads Icon Related Downloads