Under the claim appeals process only some claims can be appealed. This is a legal process and only certain people and certain providers may submit the appeal, depending on the appeal type. Be sure to read each of the requirements to ensure the appropriate document is submitted with the appeal.
What can be appealed?
Only charges denied because the service is not covered by TRICARE or not medically necessary may be appealed. Your TRICARE Explanation of Benefits (EOB) or provider remittance will indicate if a denied charge is appealable. If the denial note does not indicate the charge can be appealed, you may request a claim review instead of an appeal.
Note: Only Point of Service (POS) charges for emergency care can be appealed. Visit our Disputing Point of Service Charges page to review other scenarios for disputing POS charges.
Who can appeal a denied claim?
- TRICARE beneficiary (or parent of a minor),
- Legal guardian of the beneficiary,
- A non-network provider (if he or she performed the service and accepted assignment on the claim),
- A network provider (if appealing a claim on his/her own behalf and the denied claim is appealable per the remittance notice) (Note: Network providers cannot bill patients for non-covered services or services denied as not medically necessary.),
- Legally appointed representatives (appeals submitted by anyone other than the above will not be accepted unless he or she has been appointed as a representative by power of attorney or by submitting an Appointment of Representative for an Appeal form), or
- An attorney, if acting on behalf of an appropriate appealing party.
How do you submit a claim appeal?
A claim appeal must be filed in writing within 90 days of the date on the EOB or provider remittance. You may use the online appeal submission form below or submit an appeal letter via mail or fax.
Complete our online appeal form – You will be able to print a preview of your appeal before it is submitted and a copy of the submitted appeal with a tracking number.
Mail or fax claim appeals and supporting documentation - There is no specific appeal form required. If you mail or fax your appeal, 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 EOB or provider remittance (not required but recommended)
- additional documents supporting the appeal (not required but recommended)
Health Net Federal Services, LLC
TRICARE Claim Appeals
PO Box 8008
Virginia Beach, VA 23450-8008
Be sure to send supporting documentation within 10 days from submission via fax (or postal mail if sending color photos).
What is the processing time for claim appeal?
A reply from Health Net Federal Services, LLC (HNFS) will usually be sent within 30 days of receiving the appeal. 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 claims will be reprocessed within 21 days of the appeal determination.