TRICARE Appeals: How to Fight a Denied Claim (2026) | TRICARE.com

## Quick answer If TRICARE denies a claim or a request for medical services, you have the right to appeal that decision. You must file a written appeal within 90 days of the date on your Summary of Care or Explanation of Benefits (EOB) to challenge the denial.

## Details *Note: TRICARE.com is an independent reference site and is not affiliated with the official TRICARE program or the Department of Defense. Visit TRICARE.mil for official policy.*

The TRICARE appeals process is used when a contractor denies authorization for a service, refuses to pay a claim, or terminates ongoing treatment. It is distinct from the grievance process, which is used for complaints about the quality of care or provider behavior.

### 1. Identify the Type of Denial Before filing, determine why the service was denied. Common reasons include: * **Medical Necessity:** The contractor believes the service isn't needed for your condition. * **Benefit Exclusion:** The service is not covered by TRICARE law or regulation. * **Inappropriate Level of Care:** You are seeking inpatient care when outpatient was deemed sufficient.

### 2. How to File (By Region) Your appeal must be submitted to the contractor responsible for your region or the specific benefit (Pharmacy or Dental). As of 2026, the contractors are: * **TRICARE East:** Humana Military. * **TRICARE West:** TriWest Healthcare Alliance. * **TRICARE Overseas:** International SOS. * **Pharmacy:** Express Scripts.

### 3. The Three Levels of Appeal If your initial appeal is denied, you can often escalate the request: 1. **Reconsideration:** A formal review by the regional contractor (must be filed within 90 days). 2. **Formal Review:** Conducted by the Defense Health Agency (DHA) if the amount in dispute meets a specific dollar threshold (for 2026, typically $60 or more). This must be filed within 60 days of the Reconsideration decision. 3. **Hearing:** If the dispute remains and the amount is $300 or more (2026 threshold), you may request a hearing before an administrative law judge.

### 4. Deadlines and Documentation Deadlines are strict. Missing the 90-day window for the initial Reconsideration usually results in a permanent denial. When filing, include: * The beneficiary's name and Social Security Number. * A copy of the Explanation of Benefits (EOB). * A letter explaining why you disagree with the denial. * Supporting documentation from your doctor (medical records, peer-reviewed studies, or letters of medical necessity).

## Who this affects * **Active Duty Service Members (ADSMs):** Though rare, ADSMs may appeal denials for supplemental care or non-covered services. * **Active Duty Family Members (ADFMs):** Frequently used for specialty care or therapy denials. * **Retirees and their families:** Often applies to TRICARE Select or For Life claims. * **National Guard and Reserve:** Members using TRICARE Reserve Select (TRS). * **Survivors:** Eligible family members continuing coverage.

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