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What is an appeal?

 

An appealThe action you take if you don’t agree with a decision made about your benefit. lets you dispute a decision made about your benefit. 

 Type of Appeal  Use when

 Factual Appeals

 

 
  • TRICARE denies payment for services or supplies you received or
  • Stops payment for services or supplies that were previously authorized.
 To learn more visit the Factual Appeals page. 

 Medically Necessity Appeals

 

TRICARE denies prior authorization for care or services because the care isn't medically necessaryTo be medically necessary means it is appropriate, reasonable, and adequate for your condition..

To learn more visit the Medical Necessity Appeals page. 

 Pharmacy Appeals

 

You disagree with a decision about your pharmacy benefit.

To learn more visit the Pharmacy Appeals page. 

 Grievance

 

You have a complaint about care you received, provider or facility behavior, or any other non-appealable issue.

 Note: If Medicare and TRICARE cover the service, you must appeal to Medicare first. To learn more, visit the Medicare-TRICARE Appeals page. 

 


Last updated: 1/20/2023

Back to FAQs Home

Last Updated 1/20/2023