Most denied authorizations can be appealed; however, the following cannot be appealed:
- Authorizations approved under Point of Service.
- Authorizations redirected and approved to a network provider when a non-network provider was requested.
- Authorizations redirected and approved to a military hospital or clinic.
- Denied Supplemental Health Care Plan (SHCP) referrals for active duty service members. Active duty service members must follow the waiver process instructions included on the denial letter.
Who can appeal a denied authorization?
- The patient may appeal.
- The parent or legal guardian of a minor child may appeal. The child must be under age 18 at the time the appeal is submitted. A non-network provider may appeal if they are listed as the rendering provider on the authorization denial. (Note: Non-network providers cannot submit an expedited appeal request. See below for expedited appeal requirements.)
- Legally appointed representatives may appeal. Appeals submitted by anyone other than the above will not be accepted unless he or she is appointed as a representative by power of attorney or by submitting an Appointment of Representative for an Appeal form.
- An attorney may submit an appeal if acting on behalf of an appropriate appealing party.
Please note: A network provider cannot submit an authorization appeal unless he or she is appointed as the beneficiary's representative. See the Appointment of Representative for an Appeal form.
How do you submit an authorization appeal?
You may submit an appeal online. via fax or by mail. Authorization appeals must be submitted within 90 days of the date on the authorization denial. However, there are additional requirements for expedited and urgent expedited appeals as noted below.
If you mail or fax your appeal, there is no specific appeal form required; however, be sure to include the following:
- the patient’s name, address, phone number and sponsor’s Social Security number (required)
- printed name of the person submitting the appeal and the relationship to the patient (required)
- the reason you are disputing the denial (required)
- a copy of the initial denial letter and any other documents related to the issue (not required but recommended)
- additional documents supporting the appeal (not required but recommended)
Complete our online appeal form – You will be able to print a preview of your appeal before it is submitted and print a copy of the submitted appeal with a tracking number.
Fax authorization appeals and supporting documentation to: 1-844-769-8007
Mail authorization appeals and supporting documentation to:
Health Net Federal Services, LLC
TRICARE Authorization Appeals
PO Box 2219
Virginia Beach, VA 23450-2219
What is the processing time for an authorization appeal?
There are three time frames for processing authorization appeals depending on the type of denial and urgency of the situation. If the denial is upheld or partially upheld, and next level appeal rights are available, they will be given in the appeal determination letter. If the denial is overturned, the authorization will be reprocessed within 21 days (usually within three days) of the appeal determination.
Non-Expedited – Processed within 60 calendar days (usually within 30 days)
All authorizations denied as "not a TRICARE benefit" are processed as non-expedited. Authorizations denied as "not medically necessary" that do not meet the requirements of urgent expedited or expedited are processed as non-expedited. If the denied services have been performed or supplied, the appeal is processed as non-expedited.
Expedited – Processed within three business days
Expedited appeals are for care that has not been rendered or if the denial is for continued inpatient stay or the patient is not yet discharged. The expedited appeal process only applies to care denied as "not medically necessary." Services denied as "not a TRICARE benefit" cannot be processed as expedited.
The expedited appeal must be filed by the beneficiary or appointed representative of the beneficiary. Providers cannot submit an expedited appeal unless he or she is appointed as a representative by the beneficiary.
It must be postmarked and received within eight calendar days of the date on the denial letter. If postmarked or received after the eighth day, the appeal will be processed as non-expedited.
Urgent Expedited – Processed within 72 hours
Urgent expedited appeals are for care that has not been provided. The urgent expedited appeal process only applies to care denied as "not medically necessary." Services denied as "not a TRICARE benefit" cannot be processed as urgent expedited.
The appeal must include a statement from the provider justifying the urgent need, where waiting three business days (expedited processing) could result in the following:
- Seriously jeopardizing the life or health of the patient or ability to regain maximum function.
- Subjecting the patient to severe pain that cannot be adequately managed without the requested care.
An urgent expedited appeal must be received or postmarked within 90 days of the denial determination letter. The request should state "Urgent Expedited Reconsideration" and be faxed to the urgent expedited number given in the denial letter.