File a Complaint
You can file two types of complaints:
- An appealThe action you take if you don’t agree with a decision made about your benefit.
- A grievance
What is an appeal?
You can file an appeal when you don't agree with a decision made about your benefit. The appeal process is different based on the benefit issue. Depending on your issue, you can file a:
- Factual appeal
- This is if we deny payment for services or supplies you received, or if we stopped payment for services or supplies previously authorized.
- Medical necessity appeal
- This is if we deny prior authorization for care or services because we feel it isn't medically necessary. Medically necessary means it must be appropriate, reasonable, and adequate for your condition.
- Pharmacy appeal
- This is if you don't agree with a decision made about your pharmacy benefit. For example, Express Scripts denies your pharmacy claim.
- Medicare-TRICARE appeal
- This is if you're eligible for both TRICARE and Medicare, and Medicare denies your services or supplies.
If your care is denied, you will receive a letter with details about how to file your appeal.
What is a grievance?
You can file a grievance when:
- You have a complaint about the quality of care you received,
- A provider or facility behaved inappropriately, or
- You have any other non-appealable issue.
The grievance may be against any member of your health care team. This includes your TRICARE doctor, your contractor, or a subcontractor.
A sponsor, parent, guardian, or other representative may file on behalf of a dependent child. >>Learn more