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Claim Denials: Appeal or Request a Review?

Wednesday, September 18, 2019

If a TRICARE claim denies, before submitting an appeal to Health Net Federal Services, LLC (HNFS), take a moment to review the differences between appeals and claim reviews. Often, a claim review can resolve the issue. Find detailed information on our Claim Appeals page.

For requests not related to claim appeals (such as, authorization appeals, authorization or referral requests, initial claim submission, etc.), HNFS offers online secure tools for those transactions. 

Appeals

What types of claim denials can be appealed?
Claims may only be appealed if the charges were denied due to the service not being covered by TRICARE or not medically necessary. This includes Point of Service charges for emergency care. The denial note on the Explanation of Benefits (EOB) will indicate whether or not the denial is appealable. 

Who can submit a claim appeal? 

  • The TRICARE beneficiary (or parent of a minor)
  • A non-network provider if he or she accepted assignment on the claim, and he or she performed the services 
  • A network provider if appealing a claim on his/her own behalf and the denied claim is appealable per the remittance notice (network providers cannot bill patients for non-covered services or services denied as not medically necessary)
  • An attorney 
  • A legal guardian of the beneficiary
  • A representative, as designated on an Appointment of Representative Form (available on our Forms page)

What are non-appealable issues?
The following are common issues that are not appealable: underpayment disputes, corrected claims, third party liability claims, and lack of other health insurance information. (This list is not all-inclusive.)

What should be included with an appeal request? 

  • An explanation of what is being appealed
  • The sponsor’s Social Security number, claim/authorization number(s), date of service (when applicable), name of the beneficiary and the beneficiary's date of birth
  • The provider's remittance notice, EOB or the determination/denial letter 
  • Supporting medical records 

How do I submit an appeal? 
In an effort to safeguard beneficiary personal health information (PHI), appeals must be sent to the appropriate department for proper processing and handling. 

  • HNFS can accept appeals one of three ways: online, via fax or via postal mail. Find submission details on our Claim Appeals page. If submitting the appeal online, be sure to send supporting documentation via fax to 844-802-2527, Attention: Supporting Documents for Online Appeal. 
  • Claim appeals must be submitted within 90 calendar days of the date on the EOB or provider remit. 
  • Do not submit appeals to PGBA, LLC, HNFS’ claims processing partner, as they are unable to process these requests. 

Claim Reviews 

Claim reviews may be requested for concerns about how a claim was processed, rather than charges denying as not covered or not medically necessary. Claim reviews must be submitted in writing within 90 calendar days of the date on the EOB or provider remit. Please include a copy of the claim, EOB, any supporting medical records, and any new information not previously submitted with the claim. 

View detailed claim review instructions on our Requesting a Claim Review page.

Point of Service (POS) Disputes

Only POS charges for emergency care may be appealed by the beneficiary as long as the appeal submission indicates the services were emergent in nature; however other POS charges may be disputed depending on the circumstance (i.e., the beneficiary received misinformation from an HNFS representative). To learn more, visit our Disputing Point of Service Charges page.