Appeals

Appeals Addresses

Office or Contractor	Appeals Address
Defense Health Agency	Defense Health Agency Appeals, Hearings and Claims Collection Division 16401 E. Centretech Parkway Aurora, CO 80011-9066 Fax: 303-676-3616
East Region	Humana Military Appeals P.O. Box 740044 Louisville, KY 40201-9973
West Region	TRICARE West Region Appeals P.O. Box 2130 Virginia Beach, VA 23450 Fax: 866-852-1994
Overseas	TRICARE Overseas Program Appeals P.O. Box 7992 Madison, WI 53707-7889 USA
TRICARE For Life	U.S. and U.S. territories: WPS-TRICARE For Life Attn: Appeals P.O. Box 7490 Madison, WI 53707-7490 All other overseas areas: TRICARE Overseas Program Appeals P.O. Box 7992 Madison, WI 53707-7889 USA
Pharmacy	Express Scripts, Inc. P.O. Box 60903 Phoenix, AZ 85082-0903

Factual Appeals

Medical Necessity Appeals

You can file a medical necessity appeal if we deny pre-authorization for care or services because we feel it isn’t medically necessary. 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
• 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.

Pharmacy Appeals

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.

Medicare-TRICARE Appeals

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