Appeals
What is an appeal?
You can file an 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 TRICARE denies payment for services or supplies you received, or if TRICARE 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 TRICARE denies 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.. 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'll receive a letter with details about how to file your appeal.
| Office or Contractor | Appeals Address |
|---|---|
| Defense Health Agency |
Defense Health Agency |
| East Region | Humana Military Appeals P.O. Box 740044 Louisville, KY 40201-9973 |
| West Region |
TRICARE West Region Appeals |
| Overseas |
International SOS Assistance, Inc. Reconsideration/Grievances Department P.O. Box 11570 Philadelphia, PA 19116 USA |
| TRICARE For Life |
U.S. and U.S. territories: All other overseas areas: |
| Pharmacy |
Express Scripts, Inc. P.O. Box 60903 Phoenix, AZ 85082-0903 |
You can file a factual appeal when TRICARE:
- Denies payment for services or supplies you received
- Stops payment for services or supplies that were previously authorized
To File a Factual 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 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.
Your contractor will review your appeal and send you an appeal decision.
- If the amount you’re appealing is less than $50, the decision is final.
- If the amount is $50 or more and the letter says the Defense Health Agency is the next level of appeal, you can request a formal review.
To Request a Formal Review
Send a letter to the Defense Health Agency. Make sure the postmark is within 60 days of the date on the appeal decision.
- Include copies of the decision, and any supporting documents.
The Defense Health Agency reviews and issues a formal review decision.
- Was the disputed amount less than $300? The decision is final.
- Was the disputed amount $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 a location convenient to both the requesting party and the government.
- An independent hearing officer issues a recommended decision.
- The Defense Health Agency director (or designee) or the Assistant Secretary of Defense for Health Affairs issues the final decision.
- Most are non-expedited.
- Expedited appeals are only to reconsider:
- The continuation of inpatient stays
- Pre-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 or other decision.
- Include a copy of the EOB or other decision.
- Include any supporting documents.
- Are you waiting for some 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. Do 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. It will issue a reconsideration decision.
- Was the disputed amount less than $300? The decision is final.
- Was the disputed amount $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 Defense Health Agency director (or designee) or the Assistant Secretary of Defense for Health Affairs issues the final decision.
Are you eligible for both Medicare and TRICARE?
| If your service is covered by: | You must appeal to: |
|---|---|
| Both Medicare and TRICARE | Medicare first |
| Only TRICARE | TRICARE |
You can file a pharmacy appeal if you disagree with a decision about your pharmacy benefit. For example, you can file a pharmacy appeal if Express Scripts denies:
- Your pharmacy claim
- Your request for medical necessity for a specific drug
- Your request for prior authorization
To file a pharmacy appeal:
Send letter to Express Scripts. Make sure the postmark is within 90 days of the date of the decision.
- State specifically why you disagree.
- Include a copy of the claim 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.
You may request a second level appeal if Express Scripts denies your appeal. The appeal decision letter from Express Scripts will include instructions for how to do this.
Last Updated 9/28/2026