Under TRICARE regulation (32 CFR 199.10), beneficiaries are entitled to an appeals
and hearing process when the MCSC or designated provider has denied authorization
of, or coverage of, services base on a medical necessity determination including
TRICARE beneficiaries are entitled to request a “fast” or expedited appeal when
the services being denied are concurrent inpatient (acute hospital, PHP, SUDRF,
RTC, SNF) or preadmission/preprocedure denials. The beneficiary must file a request
for an expedited appeal within 3 calendar days of receipt of the initial denial
determination. Appeals filed after the expedited appeal filing deadline will be
considered as a non-expedited appeal.
For purposes of determining when the beneficiary received the initial denial determination,
either documented date of receipt of the denial determination letter or 5 calendar
days after the initial denial determination is mailed will be accepted.
Appeals involving retrospective inpatient services or preadmission/preprocedure
appeals received after the expedited appeal deadline will be reviewed as non-expedited
Who Can Appeal
- TRICARE beneficiary or authorized representative
- Minor beneficiary
- Custodial parent or legally appointment guardian of an incompetent or minor beneficiary
- Authorized representative of a deceased beneficiary's estate
- Participating provider of services (except network providers with recourse through
a contractual provision or the state court system)
- Non-network provider appealing a preadmission/preprocedure denial
What May Not Be Appealed to TQMC
- Allowable costs or charges for services or supplies
- Determination of eligibility as a TRICARE beneficiary
- Availability of services at a military treatment facility
- Provider sanctions
- Denial of services or supplies received from a provider not authorized to provide
care under TRICARE
- Denial of referral or services by a primary care manager
- Services or supplies which are not a TRICARE benefit.
For expedited appeals, upon receipt of the complete medical records, KEPRO TQMC
will complete reconsideration for concurrent inpatient services within 2 working
days and notify all parties within 3 working days.
For expedited preadmission/preprocedure appeals, KEPRO TQMC will complete reconsideration
and notify all parties within 3 working days.
For all other appeal requests, KEPRO TQMC will provide a determination and notify
all parties within 30 days.
For all appeals, the TQMC determination will be in writing and will include any
and all applicable appeal rights.
MCSC and/or Designated Provider Responsibility
MCSCs and/or Designated Providers will be required to submit the following information:
- Complete medical records pertaining to the appeal
- Appeal request
- Initial denial determination letter
- Reconsideration determination letter (for non-expedited appeals)
- Any other pertinent information to the appeal
- Appeal Summary Log (Form 607)