TRICARE Denials

TRICARE Claim Appeals

Only charges denied because the service is not covered by TRICARE or not medically necessary may be appealed. The TRICARE Explanation of Benefits (EOB) or provider remittance will indicate if a denied charge is appealable. If the denial note does not indicate the charge can be appealed, you may request a claim review instead of an appeal.

Note: Only Point of Service (POS) charges for emergency care can be appealed. Visit the TRICARE Disputing Point of Service Charges page to review other scenarios for disputing POS charges.

Who can appeal a denied claim?

  • TRICARE beneficiary (or parent of a minor), 
  • Legal guardian of the beneficiary,
  • A non-network provider (if he or she performed the service and accepted assignment on the claim),
  • A network provider (if appealing a claim on his/her own behalf and the denied claim is appealable per the remittance notice) (Note: Network providers cannot bill patients for non-covered services or services denied as not medically necessary.),
  • Legally appointed representatives (appeals submitted by anyone other than the above will not be accepted unless he or she has been appointed as a representative by power of attorney or by submitting an Appointment of Representative for an Appeal form), or
  • An attorney, if acting on behalf of an appropriate appealing party.

How do you submit a claim appeal?

A claim appeal must be filed in writing within 90 days of the date on the EOB or provider remittance. The appeals options are to use the online appeal submission form, or submit an appeal letter via mail or fax. 

A TRICARE Fact Sheet on the Appeals process is available here: https://www.cannon.af.mil/Portals/85/documents/TRICARE%20Appeals%20Process.pdf

For more information: https://www.tricare-west.com/content/hnfs/home/tw/prov/claims/claim_appeals.html