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TRICARE Operations Manual 6010.62-M, April 2021
Appeals And Hearings
Chapter 12
Section 6
Defense Health Agency (DHA) Appeals
1.1  Assistance To Beneficiaries
The contractor and the TRICARE Quality Monitoring Contract (TQMC) contractor shall provide beneficiaries, or other qualified persons requiring assistance (e.g., providers, representatives), 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 or information which may have a bearing on the matter in dispute.
1.2  Assistance To DHA
1.2.1  The contractor and the TQMC contractor shall provide, upon DHA request, the complete file(s) covering the claim(s) and reconsideration(s) in dispute when DHA receives a request for a formal review or hearing (See Section 3 for requirements).
1.2.2  The contractor shall have the capability to send and receive secure electronic files to protect Personally Identifiable Information (PII) and Protected Health Information (PHI).
1.2.3  The DHA Office of General Counsel (OGC) will request the entire appeal file by telephone, secure email, or facsimile.
1.2.4  The contractor shall 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.
1.2.5  The contractor shall copy the entire file (making one-sided copies only) and mail it by overnight mail to the DHA OGC or on the same day through secure electronic transmission unless the contractor submits a request for extension by telephone or email. In no event will the extension exceed five business days after receipt of the request.
1.2.6  The contractor shall, upon request, assist DHA in developing additional information to fully develop facts in the case.
1.2.7  The contractor and TQMC contractor shall provide and update DHA OGC with the Points of Contact (POCs) responsible for coordination of appeal functions to include names, email addresses, and telephone numbers.
2.1  The contractor and the TQMC contractor shall forward any written appeal inquiries regarding an appeal which is at the DHA level to: DHA OGC, 16401 E. Centretech Parkway, Aurora, Colorado 80011-9066.
2.2  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.
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.
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