Reasons for Appeal
Content Provided by LIFELines
Most military folks are familiar with the TRICARE system, which serves our health-care and pharmaceutical needs. Because most doctors are TRICARE providers, we usually don't have a problem with service. Once in a while, however, an obstacle comes up when patients are denied services or medical equipment they think they're entitled to. Thankfully, there is a fair and simple process for filing an appeal.
You can file a claim if your medical circumstance falls under one of three appeal criteria: you believe a service was unfairly denied, you feel that further hospital stay is needed for a full recovery, or you believe a preauthorization was denied. Health Net Federal Services grants preauthorizations for TRICARE-covered services in certain situations.
A preauthorization might be granted, for example, when a patient needs to see a neurosurgeon located in a different city and the patient's local hospital doesn't have one. Preauthorizations are denied when Health Net Federal Services determines that the procedure requested is not medically necessary, the particular benefit is not covered by TRICARE, or the request is for an inappropriate level of care -- for example, wanting to stay overnight in a hospital for a minor surgery.
To appeal a denied claim or authorization, complete a letter of reconsideration. This letter must include, among other important details, the patient's name, address, and phone number, the sponsor's Social Security number, and the reason for appeal. A full description of the letter of reconsideration and an explanation of the entire appeals process can be found either in the TRICARE Handbook or at Health Net Federal Services
Members who are enrolled in TRICARE Standard are responsible for submitting claims to the appropriate claims processor. Health-care providers of members enrolled in TRICARE Prime submit the claims on behalf of the beneficiary. The additional forms to be used by providers and beneficiaries can be downloaded from TRICARE.
Types of Appeals
For most claims, file a "non-expedited preauthorization appeal," which requires you to complete the letter of reconsideration within 90 days of the denial. A response notifying you of the decision and any other appeal rights will then be sent to you within 30 days.
If you are denied admission to a hospital or you are denied a medical procedure, you can file an "expedited review of a preadmission/preprocedure denial." This appeal must be filed within three calendar days after the initial denial, in which case you will receive a response no later than three days after the request has been received.
Finally, if an extended hospital stay is denied, you can file a "concurrent review denial" by submitting the appeal no later than noon the day following receipt of the initial denial. A response should be received within three days of the request.
What You Can't Appeal
There are three reasons for which appealing is not appropriate and will not be considered. First, you cannot appeal the amount TRICARE will pay for a service. Second, if you receive services or care from a provider who is not authorized under the TRICARE program, you cannot appeal. Most health-care providers are TRICARE approved; however, it's wise to consult with TRICARE before being seen by a doctor you don't know. Finally, if you were not eligible for TRICARE to begin with, then filing a claim is futile.
If your reconsideration is denied and you're not satisfied with the decision, you can request a second-level review. These types of reviews are not guaranteed and are based on specific details of the initial claims. Upon receipt of the initial denial letter, you will be given instructions and a timeframe for filling out the second-level review. If the request in dispute is more than $300 and you are not satisfied with the second-level review, you can request a hearing. The hearing information is disclosed only if and when an appeal reaches that level.