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TRICARE Operations Manual 6010.59-M, April 1, 2015
Appeals And Hearings
Chapter 12
Section 6
Defense Health Agency (DHA) Appeals
1.0  Responsibilities And Procedures
1.1  Assistance To Beneficiaries
The contractor and the TRICARE Quality Management Contract (TQMC) contractor shall provide beneficiaries, or other qualified persons requiring assistance, 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 and/or information which may have a bearing on the matter in dispute.
1.2  Assistance To Defense Health Agency (DHA)
1.2.1  When DHA receives a request for a formal review or hearing, the contractor and the TQMC contractor will be requested to furnish the complete file(s) covering the claim(s) and reconsideration(s) in dispute. (See Section 3, paragraph 4.5 for requirements.) The DHA Office of General Counsel (OGC) will request the entire appeal file by telephone, facsimile transmission (fax). The contractor will 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. The contractor shall copy the entire file (making one-sided copies only) and mail it by express mail to the DHA OGC, as soon as possible.
1.2.2  In no case shall the sending of the file occur later than five workdays after receipt of the request. In addition, upon request, the contractor shall assist DHA in developing additional information as may be necessary to fully develop facts in the case. To facilitate communications between DHA, the TQMC contractor, and the contractor, the names of specific persons in the centralized appeal unit who are responsible for coordination of appeal functions shall be furnished to the DHA OGC Point Of Contact (POC) and the TQMC contractor by the contractor. Names and phone numbers shall be updated as necessary and notice provided.
2.0  Questions Regarding Appeals
Written inquiries received by a contractor or the TQMC contractor regarding an appeal which is at the DHA level shall be forwarded to DHA OGC, 16401 E. Centretech Parkway, Aurora, Colorado 80011-9066, for response. 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.
3.0  Contractor Determinations Reversed By The Appeal Process
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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