An appeal under TRICARE is
an administrative review of program determinations made under the
provisions of law and regulation. An appeal cannot challenge the
propriety, equity, or legality of any provision of law or regulation. This
chapter sets forth the policies and procedures for appealing decisions
made by TRICARE or TRICARE contractors that adversely affect the
rights and liabilities of beneficiaries and participating providers,
and providers denied the status of an authorized provider under
TRICARE.
2.0 AUTHORITY
The procedures and principles
included in this chapter are based on the requirements of 32
CFR 199.10. For additional information regarding the
appeal process refer to Chapter 13, Section 5 and
the TRICARE Policy Manual (TPM), Chapter 1, Section 4.1 and 32
CFR 199.15(g), (h), and (i).
3.0 CONTRACTOR
RESPONSIBILITIES
The
contractor shall approve or deny the rights of appealing parties
at all levels of the appeal process in which the contractor participates.
3.1 The contractor
is responsible for all levels of the appeal process until a final
resolution is reached, including, where appropriate, timely payment
following a reversal.
3.2 Initial Determinations
3.2.1 The
contractor shall develop a written plan and implement a formal appeal
process that incorporates the requirements for initial medical necessity
and factual determinations set forth below. In any case when the initial
determination is adverse to the beneficiary or non-network participating
provider, the notice shall include a statement of the right to appeal
the determination. For reporting requirements, see DD Form 1423,
Contract Data Requirements List (CDRL), located in Section J of
the applicable contract.
3.2.2 The
contractor shall issue a dated initial determination in the form
of an Explanation of Benefits (EOB) or a letter. The initial determination
shall contain sufficient information to enable the beneficiary or
provider to understand the basis for the denial. The initial determination
shall state with specificity what services and supplies are being
denied and for what reason.
3.2.3 The
contractor shall retain a legible hardcopy or digital copy of the
initial determination or be able to produce a duplicate EOB from
digital records upon request. The initial determination shall include
adequate notice of appeal rights and requirements. If a request
for authorization for services or supplies is denied and a claim
is later submitted, the claim will render the preauthorization request
moot.
3.3 TRICARE/Medicare Dual Eligible
- Initial Determinations
3.3.1 Services
and supplies denied payment by Medicare will not be considered for
coverage by TRICARE if the Medicare denial of payment is appealable
under the Medicare appeal process.
3.3.2 If Medicare
denies the appeal, Medicare’s decision is final and no appeal is
available under TRICARE.
3.3.3 If,
however, a Medicare appeal results in some payment by Medicare,
the services and supplies covered by Medicare will be considered
for coverage by TRICARE.
3.3.4 Services
and supplies denied payment by Medicare will be considered for coverage
by TRICARE if the Medicare denial of payment is not appealable under
the Medicare appeal process.
3.3.5 The appeal
procedures set forth in this chapter are applicable to initial denial
determinations by TRICARE under the TRICARE Medicare Eligible Program
(TMEP).
3.3.6 A flow chart diagramming the
appeal process relating to TMEP appeals is at Addendum
A, Figure 12.A-7.
3.4 Written
Notice Of Initial Determination (Not EOB)
Suggested wording for a non-expedited
written appeal notice (including factual determinations) can be
found Addendum A, Figure 12.A-8.
3.5 Suggested
Modified Wording For An Appeal Of A Preadmission or Preprocedure
Initial Denial Determination
Suggested wording for an appeal
of a preadmission or preprocedure denial determination can be found
at Addendum A, Figure 12.A-9.
3.6 Suggested
Modified Wording For An Appeal Of A Concurrent Review Initial Denial
Determination
Suggested
wording for an appeal of a concurrent review initial denial determination
can be found at Addendum A, Figure 12.A-10.
3.7 Submission
Of Reconsideration Requests
The contractor shall establish
unique post office boxes or addresses and email addresses to receive
reconsideration requests.
4.0 WAIVER
OF LIABILITY
The
contractor shall, if applicable, apply a waiver of liability as
it applies to the beneficiary and non-network provider for services
found not to be medically necessary, at an inappropriate level,
custodial care, or other reasons relative to reasonableness, necessity
or appropriateness of care, shall be addressed in the initial determination.
5.0 UNDELIVERABLE
INITIAL DETERMINATIONS
The
contractor shall follow the procedures set forth in Chapter
8, Section 6 if the notice of initial determination
is returned as undeliverable.
8.0 REPROCESSING
OF CLAIMS AND PREADMISSION OR PREPROCEDURE REQUESTS FOLLOWING ISSUANCE
OF RECONSIDERATION DETERMINATIONS, FORMAL REVIEW DETERMINATIONS
AND HEARING FINAL DECISIONS
8.1 The
contractor shall return to Defense Health Agency (DHA) any formal
review determination of hearing final decision misdirected to the
contractor.
8.2 DHA
will provide the appropriate contractor with a copy of the formal
review determination and hearing final decision.
8.3 All contractor
determination reversed in whole or in part by the contractor’s or
the TRICARE Quality Monitoring Contract (TQMC) contractor’s reconsideration
determination, the DHA formal review determination, or by the contractor
in accordance with the standards set forth in
Chapter 1, Section 3.