Certain treatments require prior authorization before TRICARE will cover them. Your provider must get approval from TRICARE before these treatments will be covered. Similarly, it is essential that you use TRICARE providers or receive prior authorization to see providers other than your Primary Care Manager, or “PCM”. If you fail to receive prior authorization before receiving these treatments, or before receiving authorization to see an outside provider, you will be subject to a $300 deductible ($600 if anyone other than the sponsor) and an additional 50 percent cost share of the maximum charge allowable under TRICARE.
If you are denied coverage under certain circumstances, you may appeal a TRICARE decision to denying authorization for treatment by filing the proper paperwork. Typically an appeal is filed when benefits are denied due to a factual determination by your provider or a determination that a certain procedure, treatment, or medication is not medically necessary or given prior authorization by your provider. In less frequent cases, coverage is denied because the beneficiary is eligible for TRICARE and Medicare (called “dual eligibility”) or because a particular provider has been sanctioned by the Defense Health Agency.
You will normally be notified in writing when an otherwise covered treatment or medication is denied, and that notification will state explicitly that you are able to appeal the decision and will usually provide the address to which you should mail your appeal. If you are unable to use the information on your written notice for any reason, visit http://www.tricare.mil/Resources/Appeals/AppealsAddresses.aspx to find the correct address, depending on the TRICARE program in question or your TRICARE geographic region.
For issues that are not subject to appeal, such as contesting the quality of care received or excluded items, you may file a grievance with your TRICARE contractor. You must submit the grievance by mail and include the following:
- Name, address, and phone number of beneficiary
- Beneficiary’s birthdate
- Social Security number of sponsor
- A description of the grievance to include all relevant information, including:
- Names of all persons or providers involved
- Location, date, and time (if applicable)
- Nature of the grievance
- Any additional pertinent details
- Any documentation that supports the grievance
- Signature of beneficiary
In the case of an appeal or of a grievance, be sure to meet all deadlines, submit all documentation in writing, and keep copies of all documentation. If you are unable to meet deadlines for documentation submission, you may be able to submit what documentation you do have along with a notice of an intent to file additional supporting paperwork.