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.