Authorization Appeals

What Can I AppealThe action you take if you don’t agree with a decision made about your benefit.?

You can appeal denied authorizations for care or services that were determined to be not medically necessaryTo be medically necessary means it is appropriate, reasonable, and adequate for your condition. or a non-covered benefit.

What Can’t I Appeal?

There also are things that you can’t appeal, including those shown below.

• TRICARE-determined allowable cost for services/supplies
• Beneficiary TRICARE eligibility
• Network provider and contractor disputes
• Services/supplies from a provider not authorized under TRICARE
• A treatment plan with a selected alternative plan
• Refusal of primary care manager to provide services or referral to a specialist
• Designation of providers to perform requested services
• Point of Service determinations (except emergency-related services)

Who Can Appeal a Denied Authorization?

Not everyone can appeal a denied authorization. Check the list below to see if you are able to.

• TRICARE beneficiaries, including minors
• Non-network participating providers of services
• Custodial parents or legal guardians on behalf of minors
• The legally appointed guardian of an adult beneficiary unable to care for themselves
• A representative appointed by the proper appealing party
  • Please complete the Appointment of Representative and Authorization to Disclose Information form, required with the appeal.
  • Note: Network participating providers can’t file an appeal without a signed Authorization of Representative form or written statement signed by the proper appealing party.
• Attorneys acting on behalf of a beneficiary or proper appealing party
• A provider that has been denied approval as an authorized TRICARE provider
• A provider who has been terminated, excluded, suspended or otherwise sanctioned

How Do I Submit an Appeal?

The fastest and easiest way to submit an appeal is through the TRICARE West Region Beneficiary Portal. You can also submit the completed Authorizations Appeals Form by fax, mail, or email.

• Fax: 866-852-1919
• Mail:
  TriWest Healthcare Alliance
  Appeals and Reconsideration Department
  P.O. Box 2636
  Virginia Beach, VA 23450
• Email: T5AppealsReconsideration@TriWest.com

What Information Do I Need to Include?

Include all the information listed below with your appeal.

• Beneficiary’s full name, address, phone number, date of birth
• Sponsor’s name and Social Security number
• Completed Authorization Appeals Form
• A signed Appointment of Representative form, if an authorized representative is submitting the appeal, including network participating providers
• A written letter or statement outlining the reason for the appeal
• A copy of the denial letter
• Additional supporting documents or medical records

What is the Deadline to File an Appeal?

There are expedited and routine appeals, each with their own deadlines.

• Submit rushed appeals within three calendar days of when you receive the denial letter.
• Submit routine appeals within 90 calendar days of when you receive the denial letter.

Related Links

Medical Necessity Appeals