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TRICARE Operations Manual 6010.62-M, April 2021
Appeals And Hearings
Chapter 12
Section 1
General
Revision:  
1.0  PURPOSE OF APPEAL PROCESS
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.
6.0  FINALITY OF INITIAL DETERMINATION
The initial determination is final and binding unless the initial determination is reopened by the contractor or revised upon appeal.
7.0  PROVIDING ASSISTANCE
To appealing parties the contractor shall:
•  Issue initial and reconsideration determinations which clearly explain appeal rights when an adverse decision is made;
•  Explain to inquirers the procedures for requesting a reconsideration, a formal review or a hearing;
•  Complete the file documentation when necessary, e.g., provide an EOB copy when an appeal is filed without a copy, or develop for additional information when the appealing party’s statements indicate a need for added support or the file indicates added development is appropriate;
•  When requested to do so, provide the appealing party a copy of the appeal file.
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.
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