TRICARE Appeals: How to Dispute a Denied Claim (2026 Guide)

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## Quick answer If TRICARE denies payment for a medical service, refuses to authorize a treatment, or terminates ongoing care, you have the right to file an appeal. You generally have 90 days from the date of the denial notice to submit a written request for a formal review to your regional contractor (Humana Military or TriWest) or Express Scripts.

In detail

The TRICARE appeals process ensures that medical necessity and policy coverage are applied fairly. However, you cannot appeal "allowable charges" (the set price TRICARE pays for a service) or provider network status; you can only appeal decisions regarding the benefit itself or the necessity of the care.

### Types of Appeals There are three primary categories of appeals, each handled by different entities:

1. **Medical Necessity Appeals:** These occur when TRICARE (or its contractor) determines a service is not "medically necessary" or is "inappropriate" for your condition. 2. **Factual Appeals:** These involve disputes over whether a specific service is a covered benefit under the law, or disputes over eligibility/enrollment status. 3. **Pharmacy Appeals:** Handled specifically by Express Scripts regarding drug coverage, quantity limits, or non-formulary status.

### The 3-Level Appeal Process Most appeals follow a hierarchical structure. You must complete one level before moving to the next:

* **Level 1: Reconsideration:** This is a review conducted by the regional contractor (Humana Military in the East, TriWest in the West). Must be filed within **90 days** of the Initial Determination. * **Level 2: Formal Review:** If Level 1 is denied and the "amount in dispute" meets specific thresholds, you may request a formal review from the Defense Health Agency (DHA). Must be filed within **60 days** of the Reconsideration decision. * **Level 3: Hearing:** Conducted by an independent hearing officer. This is generally reserved for cases where the amount in dispute is significant (e.g., $300+ for most plans).

### Filing Deadlines and Requirements | Action | Deadline | Contractor | | :--- | :--- | :--- | | **Initial Appeal (Reconsideration)** | 90 days from denial | Humana (East) / TriWest (West) | | **Pharmacy Appeal** | 90 days from denial | Express Scripts | | **Expedited Appeal** | 3 days (for urgent care) | Regional Contractor |

### Expedited Appeals If you are currently an inpatient in a hospital or skilled nursing facility and TRICARE notifies you that coverage for your stay is being terminated, you can request an **Expedited Appeal**. This must be done by noon of the day following the notification. This prevents you from being discharged while the immediate necessity of the care is reviewed.

## Who this applies to * **TRICARE Prime (All Regions):** Applies when a Primary Care Manager (PCM) referral is denied or a civilian specialist's treatment plan is rejected as not medically necessary. * **TRICARE Select:** Applies if a claim is denied after the fact because the service was deemed "investigational" or outside of covered benefits. * **TRICARE For Life (TFL):** Usually involves services covered by TRICARE but not Medicare. If Medicare denies a claim, you must appeal through Medicare first. * **Active Duty Service Members (ADSMs):** While ADSMs have a different waiver process for some "fitness for duty" care, they still use the standard appeal process for denied claims regarding family members or non-duty-related care.

Common scenarios

### Scenario 1: The "Investigational" Denial A TRICARE Select beneficiary in the East Region receives a $2,500 bill for a new type of laser surgery. Humana Military denies the claim, labeling it "investigational." The beneficiary has 90 days to submit clinical peer-reviewed journals and a letter from their doctor proving the surgery is now standard of care to initiate a Level 1 Reconsideration.

### Scenario 2: Pharmacy Quantity Limit A retiree using TRICARE Prime is prescribed a specific brand-name medication. Express Scripts denies the claim because the doctor prescribed 60 pills for a 30-day period, exceeding the "quantity limit." The beneficiary’s doctor must submit a factual appeal explaining why the higher dosage is medically required for this specific patient.

### Scenario 3: Termination of Inpatient Care A patient in a rehabilitation facility is told TRICARE will stop paying on Friday because they have reached "maximum medical improvement." The patient disagrees. They must file an expedited appeal by noon on Thursday to ensure the case is reviewed before the payment cutoff.

## Related terms * **Initial Determination:** The original notice (often an Explanation of Benefits or EOB) that tells you a claim or service is denied. * **Amount in Dispute:** The dollar amount TRICARE would have paid if the claim were approved; this determines if you can move to Level 2 or 3 appeals. * **Medically Necessary:** Care that is appropriate, reasonable, and adequate for your condition according to clinical standards. * **Explanation of Benefits (EOB):** The document sent to you after a claim is processed; it contains the specific "denial codes" needed to start an appeal. * **Grievance:** Distinct from an appeal; a grievance is a complaint about the *quality* of care or service (e.g., a rude doctor), not a dispute over payment.

## Sources * **TRICARE.mil Appeals Page:** https://www.tricare.mil/appeals * **Defense Health Agency (DHA) - Appeals & Hearings:** https://health.mil/Military-Health-Topics/Business-Support/Appeals-and-Hearings * **Humana Military (East Contractor):** https://www.humanamilitary.com/beneficiary/claims/appeals-grievances * **TriWest Healthcare Alliance (West Contractor):** https://www.triwest.com/beneficiary/appeals-and-grievances/