How to Appeal a TRICARE Denial: 2026 Guide | TRICARE.com

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## Quick answer If TRICARE denies a claim or a request for medical services, you have the right to appeal the decision in writing within 90 days. You must submit your appeal to the specific contractor that issued the denial (Humana Military for the East, TriWest for the West, or Express Scripts for pharmacy) and include evidence showing why the service should be covered.

Details

The TRICARE appeals process varies depending on whether you are disputing a **medical necessity** denial, a **factual** denial (like eligibility or double coverage), or a **pharmacy** denial.

### 1. Identify the Reason for Denial Before filing, check your Explanation of Benefits (EOB) or the letter sent by your regional contractor. Common reasons include: * The service is considered "not medically necessary." * The treatment is "experimental or unproven." * You did not obtain a required prior authorization (common in TRICARE Prime). * The provider is not TRICARE-authorized.

### 2. Time Limits and Deadlines For the 2026 plan year, the following deadlines apply: * **Initial Appeal:** Must be filed within **90 days** of the date on the denial notice or EOB. * **Expedited Appeals:** If you are currently inpatient and the denial is for continued stay, you can request an expedited appeal, which is usually processed within 72 hours.

### 3. Where to Send Your Appeal Your appeal must be sent to the contractor responsible for your region or benefit: * **East Region:** Humana Military. * **West Region:** TriWest Healthcare Alliance. * **Pharmacy:** Express Scripts. * **Overseas:** International SOS.

### 4. Required Documentation A successful appeal usually requires more than just a letter of disagreement. You should include: * Your name, address, and telephone number. * The Sponsor’s Social Security Number or Member ID. * A copy of the EOB or denial letter. * **Clinical Support:** A letter from your doctor explaining why the treatment is medically necessary and citing peer-reviewed medical literature if the service was denied as "experimental."

### 5. The Three Levels of Appeal If your first appeal (Reconsideration) is denied, you can move to higher levels: 1. **Reconsideration:** Conducted by the regional contractor. 2. **Formal Review:** Conducted by the Defense Health Agency (DHA) if the amount in dispute is over $50. 3. **Hearing:** Held before an administrative law judge if the amount in dispute is $300 or more (2026 threshold).

## Who this affects * **Active Duty Service Members (ADSMs):** Note that ADSMs often have distinct "Waiver of Liability" rules but must still follow the appeal chain for civilian care. * **Active Duty Family Members (ADFMs):** Covered under Prime or Select. * **Retirees and their families:** Including those on TRICARE for Life (TFL). * **National Guard and Reserve:** Those enrolled in TRICARE Reserve Select (TRS) or Retired Reserve (TRRR). * **Survivors:** Eligible family members of deceased service members.

## Sources * TRICARE Appeals Page: [https://www.tricare.mil/appeals](https://www.tricare.mil/appeals) * Humana Military (East): [https://www.humanamilitary.com/](https://www.humanamilitary.com/) * TriWest Healthcare Alliance (West): [https://www.triwest.com/](https://www.triwest.com/) * Defense Health Agency (DHA): [https://health.mil/](https://health.mil/)