Appeals

What is an appealThe action you take if you don’t agree with a decision made about your benefit.?

You can file an appeal when you don't agree with a decision made about your benefit. The appeal process is different based on the benefit issue. Depending on your issue, you can file a:

• Factual appeal
  • This is if we deny payment for services or supplies you received, or if we stopped payment for services or supplies previously authorized.
  • Your regional contractor sends you an appeal decision. If you disagree with the decision, follow the guidelines for factual appeals. 
• Medical necessity appeal
  • This is if we deny pre-authorization for care or services because we feel it isn't medically necessaryTo be medically necessary means it is appropriate, reasonable, and adequate for your condition.To be medically necessary means it is appropriate, reasonable, and adequate for your condition.. Medically necessary means it must be appropriate, reasonable, and adequate for your condition.
  • Your regional contractor sends you an appeal decision. If you disagree with the decision, follow the guidelines for medical necessity appeals. 
• Pharmacy appeal
  • This is if you don't agree with a decision made about your pharmacy benefit. For example, Express Scripts denies your pharmacy claim.
• Medicare-TRICARE appeal
  • This is if you're eligible for both TRICARE and Medicare, and Medicare denies your services or supplies.

If your care is denied, you will receive a letter with details about how to file your appeal.