File a Complaint
You can file two types of complaints:
- An appealThe action you take if you don’t agree with a decision made about your benefit.
- A grievance
What is an appeal?
You can file an appeal when you don't agree with a decision made about your benefit. The appeal process is different based on the benefit issue. Depending on your issue, you can file a:
- Factual appeal
- This is if we deny payment for services or supplies you received, or if we stopped payment for services or supplies previously authorized.
- Medical necessity appeal
- Pharmacy appeal
- This is if you don't agree with a decision made about your pharmacy benefit. For example, Express Scripts denies your pharmacy claim.
- Medicare-TRICARE appeal
- This is if you're eligible for both TRICARE and Medicare, and Medicare denies your services or supplies.
If your care is denied, you will receive a letter with details about how to file your appeal.
What is a grievance?
You can file a grievance 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.
The grievance may be against any member of your health care team. This includes your TRICARE doctor, your contractor, or a subcontractor.
A sponsor, parent, guardian, or other representative may file on behalf of a dependent child. >>Learn more