Military Health System

The TOP contractor shall perform initial determinations. Initial denial determinations shall be appealed/directed to the TOP contractor. The contractor shall perform the reconsideration review, to include research and consideration of any purchased care sector practice patterns or other cultural differences that are relevant to the case (see paragraph 2.3). If the TOP contractor upholds the denial in whole or in part, the contractor shall notify the beneficiary in writing of further appeal rights.

The TOP contractor shall perform initial determinations. When authorization or payment is denied by the TOP contractor, the Service member or their appointed representative may appeal the denial to the designated Specified Authorization Staff (SAS). The TOP contractor shall furnish the Service member with clear guidance, in writing, for filing an appeal with the SAS. If the SAS upholds the denial in whole or in part, the SAS will notify the Service member of further appeal rights with the appropriate Surgeon General’s office. If the denial is overturned at any level, the SAS will notify the TOP contractor and the Service member of the results. The TOP contractor shall maintain a log by TRICARE Area Office (TAO) region of overturned denials.

Prior to issuing a reconsideration determination, the TOP contractor shall conduct research to determine whether there are unique purchased care sector practice patterns or other cultural differences unique to foreign health care that may be relevant to the beneficiary’s case. The TOP contractor shall document any relevant practice patterns or cultural differences and shall consider the potential impact of these issues during the reconsideration process. This documentation shall be included in the file documentation identified in Chapter 12, Section 3.