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Disputing Point of Service Charges

Please review the following scenarios to determine how to dispute Point of Service charges.

Emergency care
If you believe the care was due to an emergency you may file a claim appeal. You may review the TRICARE definition of emergency care to determine if an appeal is appropriate.

You contacted your PCM after the service, you did not know a referral was needed, the service was a follow up to preventive care, or you did not realize the referral had expired
As a TRICARE Prime beneficiary it is your responsibility to be aware of the referral requirements. Point of Service charges cannot be waived if you did not follow the referral requirements. Your PCM/military hospital or clinic cannot submit a retroactive referral for these circumstances.

Your military PCM/military hospital or clinic appointment line/referral manager failed to submit the referral to HNFS or gave you misinformation
HNFS advises beneficiaries to contact the military hospital’s or clinic’s patient advocate to determine if he/she will submit a referral for services already rendered. If the referral is approved, beneficiaries can then contact HNFS for a claims adjustment. There are no review rights through HNFS for this circumstance and the military hospital or clinic determination is final.

Your civilian PCM failed to submit the referral to HNFS or the referral was submitted and rejected
If your PCM gave you a written referral, but did not submit a referral to HNFS, you may submit a copy of the written referral. If the referral was verbal, you may submit a written statement from the provider indicating when the verbal referral was given. Submit the documentation with a copy of the Explanation of Benefits to:

TRICARE West – Claims Correspondence
PO Box 202100
Florence, SC 29502-2100                     

You did not know your PCM changed
All initial PCM assignments and PCM changes result in a notification to the beneficiary showing the assigned PCM. If you believe the PCM assignment is incorrect, you may contact us at 1-844-866-WEST (1-844-866-9378). However, Point of Service charges cannot be waived because you did not know your PCM assignment. 

Misinformation from an HNFS customer service representative
If our customer service records indicate misinformation or incomplete information was provided, the Point of Service charges may be adjusted. You may submit a request for review online or via U.S. mail.

Online: Log in to use the "Ask Us Secure Email" feature.

U.S. mail: 
TRICARE West – Claims Correspondence
PO Box 202100
Florence, SC 29502-2100        

Other reasons not listed above
You may submit a request for review online or via U.S. mail.

Online: Log in to use the "Ask Us Secure Email" feature.

U.S. mail:
TRICARE West – Claims Correspondence
PO Box 202100
Florence, SC 29502-2100