Factual Appeals

Factual determinations involve issues other than medical necessity, such as determining whether the service is covered under TRICARE policy or regulation.  Keep copies of all paperwork.

  1. Send a letter to the address specified in the notice of the right to appeal listed on your explanation of benefits (EOB) or other decision. Your appeal must be postmarked or received within 90 days of the date on the EOB or other decision. Include a copy of the EOB or other decision along with any documents that support your position. If you can't get all the supporting documents in time, send the appeal and state that you will be submitting additional information in the near future.
  2. If you are appealing an amount less than $50, the TRICARE contractor's decision is final.  If you are appealing an amount more than $50 and the letter identifies the Defense Health Agency (DHA) as the next level of appeal, you can request a formal review.
  3. To request a formal review, send a letter to the DHA within 60 days (postmarked or received) of the date on the initial determination or reconsideration decision. Include copies of the decision along with additional supporting documents.
  4. The DHA will issue a formal review decision. If the disputed amount is less than $300, the DHA's decision is final. If the disputed amount is more than $300, you can request an independent hearing.
  5. To request an independent hearing, send a hearing request to the DHA within 60 days (postmarked or received) of the date of the decision being appealed.  Include a copy of the formal review decision being appealed and any supporting documents not previously submitted. 

An independent hearing officer will conduct the hearing at a location convenient to both the requesting party and the government.  The hearing officer will issue a recommended decision and the DHA director (or designee) or the Assistant Secretary of Defense for Health Affairs will issue the final decision.

Appeals and appeal correspondence for the DHA should be addressed to:

Defense Health Agency
Appeals, Hearings and Claims Collection Division
16401 E. Centretech Parkway
Aurora, CO  80011-9066

Last Updated 11/14/2013

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