TRICARE and You: Appeals and grievances

Written by Lt. j.g. Colleen McCue

This blog is the most recent in a series helping members of the Coast Guard family understand how to use their TRICARE benefits. The blog series will continue every Monday, right here on Coast Guard All Hands.

Are you unhappy with a benefit-related decision from your TRICARE contractor or Defense Health Agency? As a beneficiary, you have the right to appeal those decisions. The appeals process varies depending on whether the denial of benefits involves a medical necessity determination, factual determination, or provider authorization. Either way, the below questions and answers may assist you:

Question: Who is able to appeal?

Answer:

  • A beneficiary or a parent/guardian of a beneficiary who is under the age of 18.
  • The parent/guardian of a beneficiary who is not competent to act on his or her own behalf.
  • A health care provider who has been denied approval as an authorized TRICARE provider, or who has been suspended, excluded, or termination.
  • A representative appointed in writing by a beneficiary or provider.

 

Question: What can be appealed?

Answer:

  • A decision denying TRICARE payments for services or supplies received.
  • A decision denying prior authorization for requested services or supplies.
  • A decision terminating TRICARE payment for continuation of services or supplies that were previously authorized.
  • A decision denying a provider’s request for approval as a TRICARE-authorized provider or expelling a provider from TRICARE.

 

Filing A Medical Necessity Appeal

Medical necessity determinations are based solely on whether, from a medical point of view, the care is appropriate, reasonable, and adequate for the particular medical condition.

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

Expedited appeal: You or an appointed representative must file an expedited review of a prior authorization denial within 3 calendar days after receipt of the initial denial.

Non-expedited appeal: You or an appointed representative must filed a non-expedited appeal no later than 90 days after receipt of the initial denial.

Process to File a Medical Necessity Appeal:

  • Send a letter to your TRICARE contractor’s address which is listed on the Explanation of Benefits (EOB). Ensure the postmark is within 90 days of EOB.
  • Include a copy of the EOB.
  • Include supporting documentation.

 

Filing A Factual Determination Appeal

Factual determinations involve issues other than medical necessity. This occurs if TRICARE denies payment for services or supplies you received, or if TRICARE stopped payment for services or supplies previously authorized.

To appeal a Factual Determination, beneficiaries should:

  • Send a letter to your TRICARE contractor’s address which is listed on the EOB. Ensure the postmark is within 90 days of the date on the EOB.
  • Include a copy of the EOB.
  • Include supporting documentation.

 

Question: What if I want to file a grievance (complaint) about the quality of care I received, an inappropriately behaved provider, or any other grievance? 

Answer: A grievance can be filed 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.

 

Question: How is a grievance submitted?

Answer:

For TRO-North region, print a Health Net Grievance Form and fax to 1-888-317-6155 or mail to:

  • Health Net Federal Services, LLC
    TRICARE Grievances
    PO Box 2399
    Virginia Beach, VA 23450-2399

 

For TRO-South region, file your grievance with Humana Military and submit in writing to:

  • Regional Grievance Coordinator
    Humana Military Healthcare Services
    8123 Datapoint Drive Suite 400
    San Antonio, TX 78229

 

For TRO-West region, print a UnitedHealthcare Military & Veterans Grievance Form and fax to 877-584-6628 or mail to:

  • UnitedHealthcare Military & Veterans
    Attn: Grievances
    PO Box 105493
    Atlanta, GA 30348

 

Question: Who can I speak to receive more information?

Answer: Call the Coast Guard’s Health Benefits Advisor Line at 800-9-HBA-HBA or call 1-800-TRICARE.

Please leave comments or questions below!

Comments

comments

Tags: , , , , ,