TRICARE Insurance Denial Appeal Guide

TRICARE provides health coverage for military service members, retirees, and families. Appeals follow a unique process through the Defense Health Agency.

TRICARE Appeal Process

TRICARE appeals differ from commercial insurance. The Defense Health Agency (DHA) oversees the program, and appeals go through a specific administrative process.

Common TRICARE Denial Reasons

  • Referral or prior authorization not obtained
  • Treatment not medically necessary per TRICARE clinical criteria
  • Provider not TRICARE-authorized
  • Treatment exceeds benefit limits
  • Experimental or investigational treatment

Appeal Levels

  1. Reconsideration — request within 90 days of the initial determination
  2. Formal Review — if reconsideration denied, request within 60 days
  3. Independent Hearing — for claims over $300, within 60 days of formal review decision
  4. TRICARE Board of Review — for claims over $300, within 60 days of hearing decision

Key Differences from Commercial Insurance

  • TRICARE uses its own clinical criteria (not InterQual or Milliman)
  • Military treatment facilities have different referral processes
  • Active duty vs retiree benefits may differ
  • Overseas TRICARE has additional considerations

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Frequently Asked Questions

Can I use a civilian doctor with TRICARE?

Yes, but you may need a referral from your PCM (Primary Care Manager) for TRICARE Prime. TRICARE Select allows direct access to any TRICARE-authorized provider. Out-of-network providers may result in higher costs.

How long does a TRICARE appeal take?

Reconsiderations are typically decided within 60 days. Formal reviews may take longer. Request expedited review if treatment delay would harm your health.

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