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.
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).
3.4 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.
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.
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.