1.2 Appeals From More Than One
Party
1.2.1 The contractor and the TRICARE
Quality Monitoring Contract (TQMC) contractor shall accept an appeal from
more than one proper appealing party.
1.2.2 The contractor
shall mail the appeal determination letters separately to each appealing
party (or representative, if a representative has been appointed)
if more than one party appeals.
1.3 Appealing
Party or Representative
1.3.1 Appeals On One’s Own Behalf
An appealing party is entitled
to file an appeal on his or her own behalf.
1.3.2 Minors And Incompetent Beneficiaries
As Appealing Parties
1.3.2.1 A minor beneficiary is a proper
appealing party.
1.3.2.2 Generally, the custodial parent
of a minor beneficiary and the legally appointed guardian of an incompetent
or minor beneficiary shall be presumed to have been appointed representative
without specific designation by the beneficiary.
1.3.2.3 The parent of a minor beneficiary
shall be presumed to be the custodial parent unless there is evidence
to the contrary.
1.3.2.4 If a parent or guardian is
pursuing the appeal on behalf of a minor beneficiary and the minor
reaches 18 years of age during the appeal, the parent or guardian
will be presumed to be authorized to continue the appeal on behalf
of the beneficiary unless the beneficiary provides a written statement
of his or her desire to pursue the appeal in his or her own behalf,
in which case the appeal decision will be mailed to the beneficiary.
1.3.2.5 Once the contractor issues
the appeal determination, the beneficiary who reached 18 years of
age during the appeal must request all subsequent levels of appeal
or appoint a representative to do so. (Refer to
paragraph 1.3.4 for
additional information relating to parents and guardians as representatives.)
1.3.3 Representative
1.3.3.1 If the proper appealing party
cannot or does not wish to pursue the appeal personally, or wishes
to have another person directly assist in pursuing an appeal, the
appealing party may appoint a representative to act in his or her
behalf at any level of the appeal process.
1.3.3.2 The appointment of a representative
must be in writing and must be signed by the proper appealing party
or an individual must be appointed to act as representative by a
court of competent jurisdiction.
1.3.3.3 All correspondence relating
to the appeal shall be directed to the representative.
1.3.4 Parents Or Guardians As Representatives
1.3.4.1 The sponsor or custodial parent
of a beneficiary under 18 years of age or the guardian of an incompetent
beneficiary cannot be an appealing party; however, such persons
may represent the appealing party in an appeal.
1.3.4.2 The custodial parent of a minor
beneficiary and the legally appointed guardian of an incompetent beneficiary
shall be presumed to have been appointed representative without
specific designation by the beneficiary; however, this presumption
shall not apply if the claim was signed by a minor and the claim
is related to abortion, substance abuse disorder, sexually transmitted
disease, or Human Immunodeficiency Virus (HIV)/Acquired Immune Deficiency
Syndrome (AIDS). (Refer to
paragraph 1.3.2 for additional information
relating to minors as appealing parties.)
1.3.4.3 A suggested format for “Appointment
of Representative and Authorization to Disclose Information” is included
at
Addendum A, Figure 12.A-1.
1.3.5 Conflict
Of Interest
1.3.5.1 To avoid possible conflict
of interest, an officer or employee of the United States (US), such
as an employee or member of a Uniformed Service, including an employee
or staff member of a Uniformed Service legal office, or a Beneficiary
Counseling and Assistance Coordinator (BCAC), subject to the exceptions
in 18 United States Code (USC) 205, is ineligible to serve as a
representative.
1.3.5.2 An exception usually is made
for an employee or member of a Uniformed Service who represents
an immediate family member.
1.3.6 Appeal
Filed By Attorney
1.3.6.1 The contractor shall assume,
absent any evidence to the contrary, that if an attorney files an
appeal on behalf of a proper appealing party, the attorney has been
duly authorized to act as the appealing party’s representative in
the appeal.
1.3.6.2 Care will be taken that the
attorney is representing a proper appealing party (e.g., an appeal
filed by an attorney as the representative of a nonparticipating
provider or as the representative of the spouse of a beneficiary,
or parent of an adult beneficiary, shall not be accepted).
1.3.7 Appeal
Filed By Provider On Behalf Of Beneficiary
1.3.7.1 Managers or administrators
of facilities or individual providers may enter appeals only as participating
providers, acting in their own behalf.
1.3.7.2 A participating provider is
not authorized to enter an appeal for a beneficiary unless the provider
has been designated by the beneficiary, in writing, to act as his
or her representative in the appeal process.
1.3.7.3 A desire to assist the beneficiary
is not, in itself, sufficient reason to permit others to act for
the beneficiary without specific appointment by the beneficiary.
1.3.8 Appeal
Filed For Deceased Beneficiary
An appeal may be filed for
a deceased beneficiary by a person authorized to sign TRICARE claims
on behalf of the deceased beneficiary under the provisions of
Chapter 8, Section 4.
1.3.9 Inquiries
Made By Members Of Congress On Behalf Of Beneficiaries
1.3.9.1 Inquiries submitted by Members
of Congress regarding a specific appealing party’s claim or claims are
not considered requests for a reconsideration. If the letter from
the Member of Congress is postmarked or received by the contractor
or TQMC contractor before the expiration of the appeal filing deadline
and is accompanied by a letter from the appealing party which meets
the requirements of a request for reconsideration, the appealing
party’s letter to the Member of Congress may be accepted as an appeal.
1.3.9.2 The contractor shall advise
the Member of Congress and the appealing party that a reconsideration will
be conducted and that the appealing party will be notified of the
results. If the Congressional inquiry is not accompanied by a letter
from the appealing party which contains all the elements of a request
for a reconsideration.
1.3.9.3 The contractor shall explain
the procedure for filing an appeal so that the Member of Congress
may advise the appealing party. Responses to Congressional inquiries
are subject to the provisions of the Privacy Act of 1974 (see
Chapter 1, Section 5) and to the provisions
of the Health Insurance Portability and Accountability Act of 1996
(HIPAA).
1.3.9.4 The contractor may tell a Member
of Congress, once an appeal has been accepted, inquiring on behalf
of an appealing party only that an appeal has been filed and that
it would be inappropriate for the contractor to comment on the case
unless the appealing party has authorized the Member of Congress,
in writing using a HIPAA release form, to receive information on
behalf of the beneficiary.
1.4 Participating
Providers
1.4.1 A non-network participating
provider is entitled to file an appeal of those claims in which
the provider participated. For the purposes of filing an appeal
of a preadmission or preprocedure denial, a non-network provider is
considered a participating provider and is entitled to file an appeal.
1.4.2 The non-network
participating provider may file an appeal instead of, or in addition
to, the beneficiary or beneficiary’s representative. Although a
network provider’s input, claims history, medical records, etc.,
may be used in adjudicating the appeal, a network provider is never
a proper appealing party. (A network provider’s disputes are handled
under the provisions of the provider’s contract or the state court
system.)
1.5 When denial of payment for
claimed services is being appealed, a non-network nonparticipating provider
is not a party to the determination and would not receive any information
regarding the claim or claim determination without the signed authorization
of the beneficiary or the beneficiary’s representative.
Exception: Peer
reviewer’s comments may be released to non-network nonparticipating
providers without the patient’s permission, since these comments
are directed toward the provider and the provider’s ability to document
treatment. In order for the non-network nonparticipating provider
to provide additional information on behalf of the patient, it is
necessary for the provider to be aware of the peer reviewer’s comments.
Note: In those cases in which a non-network
participating provider files an appeal and the care also involves
a network provider (e.g., a non-network participating professional
provider renders care to a beneficiary in a network hospital), the
non-network participating provider would be considered a proper
appealing party.
1.6 Providers Denied Certification
1.6.1 A non-network
provider who has been denied certification as an authorized provider
under TRICARE is entitled to appeal the initial determination made
by either the contractor or Defense Health Agency (DHA).
1.6.2 These
initial determinations are considered factual initial determinations
(see
Section 5). When the denial is based on the
exclusion of the provider by another Federal or federally funded
program, e.g., Medicare or Medicaid, because of fraud or abuse,
the issue is not appealable through the TRICARE appeal system. An
amount in dispute is not required for a provider to appeal a denial
of certification.
1.6.3 A contractor determination
denying network provider status to an authorized provider is not appealable.
Additional information relating to the appeal process is included
in
Chapter 13, Section 5.