Beneficiary Information and Appeals

Beneficiary Information and Appeals

Under TRICARE regulation (32 CFR 199.10), beneficiaries are entitled to an appeals and hearing process when the Managed Care Support Contractors (MCSC) or designated provider has denied authorization or coverage of services based on a medical necessity determination including pharmacy benefits.

Expedited Appeals

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 three 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 five 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 appeals.

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 that are not a TRICARE benefit

TQMC Responsibility

For expedited appeals, upon receipt of the complete medical records, KEPRO TQMC will complete reconsideration for concurrent inpatient services within two working days and notify all parties within three working days.

For expedited preadmission/preprocedure appeals, KEPRO TQMC will complete reconsideration and notify all parties within three 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)