Requesting a Claim Review
If you have a concern about how a claim processed, you can request a claim review, also called an allowable charge review. (Note: This process is separate from the claims appeals process, which is only for charges denied as "not covered" or "not medically necessary.")
Common Reasons for a Claim Review
- allowed amount disputes
- charges denied as "Included in a paid service."
- charges denied as "Requested information not received."
- claim denied as "Provider not authorized."
- ClaimsXten™ denials
- coding issues
- cost-share and deductible issues
- eligibility denials
- other health insurance issues
- penalties for no authorization
- Point of Service disputes (Exception: Point of Service for emergency services is appealable.)
- third party liability issues
- timely filing limit denials
- wrong procedure code
How to Request a Claim Review
Your request must be postmarked or received by Health Net Federal Services, LLC (HNFS) within 90 calendar days of the date on the beneficiary's TRICARE Explanation of Benefits or the Provider Remittance.
Include the following:
- letter with the reason for requesting the claim review
- copy of the claim if available
- copy of the Explanation of Benefits or Provider Remittance
- supporting medical records
- any new information that was not submitted with the original claim
Send the request to:
Health Net Federal Services, LLC
c/o PGBA, LLC/TRICARE
TRICARE West – Claims Correspondence
PO Box 202100
Florence, SC 29502-2100