What Can Be Appealed
You can appeal the following types of issues and there are different processes for each:
Factual:
- When TRICARE has denied payment for services or supplies received.
- When TRICARE terminates payment for services or supplies that were previously authorized.
- Learn about the factual appeals process.
Medical Necessity:
- When TRICARE denies prior authorization for requested services or supplies.
- Learn about the medical necessity appeals process.
Dual-Eligible (For beneficiaries eligible for both TRICARE and Medicare):
- When Medicare and TRICARE have both denied a claim and you have successfully appealed the Medicare claim (they paid the claim).
Note: If Medicare paid a claim and TRICARE did not, you can appeal the TRICARE decision through the Factual claim process.
Last Modified:May 19, 2010
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