Medical Necessity Appeals

You can file a medical necessity appealClick to closeThe action you take if you don’t agree with a decision made about your benefit. if we deny prior authorization for care or services because we feel it isn’t medically necessaryClick to closeTo be medically necessary means it is appropriate, reasonable, and adequate for your condition.

Medical necessity appeals can be either expedited or non-expedited.

  • Most are non-expedited.
  • Expedited appeals are only to reconsider the continuation of inpatient stays or prior authorization of services.
  • The denial decision explains how to file an expedited appeal.
  • Keep copies of everything for your records.

To File a Medical Necessity Appeal:

  • Send a letter to your contractor's address. Make sure the postmark is within 90 days of the date on the explanation of benefits (EOB) or other decision.
  • Include a copy of the EOB or other decision.
  • Include any supporting documents.
  • If you don’t have all the supporting documents, send the appeal with what you have. Make sure to state that you’ll send more information soon.

The contractor sends you an appeal decision. If you disagree with the decision, you can request a reconsideration from the TRICARE Quality Monitoring Contractor.

To Request a Reconsideration Decision:

Send a letter to the TRICARE Quality Monitoring Contractor. Make sure the postmark is within 90 days of the date on the appeal decision.

  • You can find the address in the appeal decision letter from your contractor.
  • Include a copy of the appeal decision.
  • Include any supporting documents.

The TRICARE Quality Monitoring Contractor reviews the case and issues a reconsideration decision.

  • If the disputed amount is less than $300, the decision is final.
  • If the disputed amount is $300 or more, you can request an independent hearing.

To Request an Independent Hearing:

  • Send a hearing request to the Defense Health Agency. Make sure the postmark is within 60 days of the date of the formal review decision.
  • Include a copy of the formal review decision.
  • Include any supporting documents you haven’t submitted before.

The independent hearing takes place at location convenient to both the requesting party and the government.

  • An independent hearing officer issues a recommended decision.
  • The final decision is issued by the Defense Health Agency director (or designee) or the Assistant Secretary of Defense for Health Affairs.  

Last Updated 12/1/2016