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What Can be Appealed

You can appeal the following types of issues and there are different processes for each:

Factual Appeals

  • 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 Appeals

Dual-Eligible Appeals

  • 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 Updated 11/14/2013