Medical Necessity Appeals
Medical necessity determinations are based solely on whether, from a medical point of view, the care is appropriate, reasonable and adequate for the condition. You may have to show medical necessity for inpatient, outpatient and specialty care.
To appeal a medical necessity decision, follow one of two processes: expedited or non-expedited. Most appeals will be non-expedited. Expedited appeals are only to reconsider approval of inpatient stays or prior authorization of services. The denial decision will explain how to file an expedited appeal. Keep copies of all paperwork.
To file a non-expedited appeal:
- 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.
- Your regional contractor will review your case and issue a reconsideration decision. If you disagree with the reconsideration decision, you can appeal to the national quality monitoring contractor.
- If needed, send a letter to the national quality monitoring contractor at the address specified in the reconsideration decision. The letter must be postmarked or received within 90 days of the date on the reconsideration decision. Include a copy of the reconsideration decision and any supporting documents.
- Finally, the national quality monitoring contractor will review the case and issue a second reconsideration decision. If you're disputing less than $300, the national quality monitoring contractor's decision is final. If you're disputing $300 or more and you disagree with the decision, you can request that the Defense Health Agency (DHA) schedule an independent hearing.
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