Back to Top Skip to main content

Health.mil: the official website of the Military Health System (MHS) and the Defense Health Agency (DHA)

Utility Navigation Links

TRICARE Operations Manual 6010.59-M, April 1, 2015
Appeals And Hearings
Chapter 12
Section 6
Defense Health Agency (DHA) Appeals
Revision:  
1.0  Responsibilities And Procedures
1.1  Assistance To Beneficiaries
The contractor and the TRICARE Quality Management Contract (TQMC) contractor shall provide beneficiaries, or other qualified persons requiring assistance, with information needed for proper filing of a request for formal review or hearing. Such assistance shall include advising of requirements for timely filing, the amounts in dispute required for filing the request, the specific matter in dispute, copies of the written determination notice(s) which is (are) being appealed, and any additional documents and/or information which may have a bearing on the matter in dispute.
1.2  Assistance To Defense Health Agency (DHA)
1.2.1  When DHA receives a request for a formal review or hearing, the contractor and the TQMC contractor will be requested to furnish the complete file(s) covering the claim(s) and reconsideration(s) in dispute. (See Section 3, paragraph 4.5 for requirements.) The DHA Office of General Counsel (OGC) will request the entire appeal file by telephone, facsimile transmission (fax). The contractor will also provide copies of nonproprietary information extracted from its agreements with network providers and non-network institutional providers involved in the formal review or hearing case if requested to do so by the DHA OGC. The contractor shall copy the entire file (making one-sided copies only) and mail it by express mail to the DHA OGC, as soon as possible.
1.2.2  In no case shall the sending of the file occur later than five workdays after receipt of the request. In addition, upon request, the contractor shall assist DHA in developing additional information as may be necessary to fully develop facts in the case. To facilitate communications between DHA, the TQMC contractor, and the contractor, the names of specific persons in the centralized appeal unit who are responsible for coordination of appeal functions shall be furnished to the DHA OGC Point Of Contact (POC) and the TQMC contractor by the contractor. Names and phone numbers shall be updated as necessary and notice provided.
2.0  Questions Regarding Appeals
Written inquiries received by a contractor or the TQMC contractor regarding an appeal which is at the DHA level shall be forwarded to DHA OGC, 16401 E. Centretech Parkway, Aurora, Colorado 80011-9066, for response. The contractor or the TQMC contractor shall inform the appealing party or representative that the case has been forwarded to DHA for review and shall advise the appealing party to address his or her questions to the DHA OGC.
3.0  Contractor Determinations Reversed By The Appeal Process
The contractor shall reprocess all determinations reversed by a formal review determination or hearing final decision in accordance with the standards set forth in Chapter 1, Section 3. For the purposes of Chapter 1, Section 3, the date of receipt is considered the date the formal review determination or hearing final decision is received by the contractor.
- END -

Utility Navigation Links

DoD Seal

tricare.mil is the official website of the Defense Health Agency (DHA) a component of the Military Health System

TRICARE is a registered trademark of the Department of Defense (DoD), DHA. All rights reserved.

CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.

If you have a question regarding TRICARE benefits, please go to the TRICARE Contact Us page page.
If you need help with technical/operational issues, please go to the TRICARE Manuals Online Frequently Asked Questions page.

The appearance of hyperlinks to external websites does not constitute endorsement by the DHA of these websites or the information, products or services contained therein. For other than authorized government activities, the DHA does not exercise any editorial control over the information you may find at other locations. Such links are provided consistent with the stated purpose of this DoD website.

v4.6.7755.23747

DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

Some documents are presented in Portable Document Format (PDF). A PDF reader is required for viewing. Download a PDF Reader or learn more about PDFs.