TRICARE Claim Denied: How to Appeal a Military Health Insurance Denial
TRICARE denied your claim? This guide covers TRICARE's appeal process, the reconsideration and formal hearing steps, VA coordination, and how to write an effective appeal letter for military health coverage.
TRICARE Claim Denied: How to Appeal a Military Health Insurance Denial
TRICARE is the health care program for active-duty service members, retirees, National Guard and Reserve members, and their families — covering approximately 9.6 million beneficiaries. Administered by the Defense Health Agency (DHA) and delivered through regional contractors (Humana Military in the East, Health Net Federal Services/Centene in the West, and International SOS overseas), TRICARE denials carry the same weight as denials from commercial insurers — and the same right to appeal.
If TRICARE has denied your claim, this guide walks through every step of the appeal process.
About TRICARE
TRICARE offers several plan options:
- TRICARE Prime: HMO-like plan requiring care from military treatment facilities (MTFs) or civilian network providers; requires referrals for specialty care
- TRICARE Select: PPO-like plan; more flexibility, no referrals required; cost-sharing applies
- TRICARE for Life (TFL): Secondary coverage for Medicare-eligible beneficiaries
- TRICARE Reserve Select (TRS): For eligible Reserve and National Guard members
- TRICARE Overseas Program (TOP): For beneficiaries living abroad
The appeal process differs slightly between plan types, but the core rights are similar.
Common TRICARE Denial Reasons
Not medically necessary: TRICARE's contractors deny claims when they determine the service does not meet TRICARE's definition of medical necessity. Medical necessity is defined in the TRICARE Policy Manual — your appeal must address the specific criteria cited.
Covered/not covered under TRICARE: TRICARE does not cover certain services — commonly cosmetic surgery, services related to PTSD or mental health if already covered by the VA, experimental treatments, and some elective procedures. However, misclassification of necessary care as "not covered" is a common wrongful denial.
Referral or prior authorization not obtained: TRICARE Prime requires referrals for specialty care. If you did not obtain a referral before receiving specialty care, the claim may be denied.
Provider not in TRICARE network: TRICARE Prime requires care from TRICARE-authorized providers. Receiving care from non-authorized providers (outside emergencies) typically results in denial.
Active duty service connection: If the injury or illness is related to military service, TRICARE may deny the claim and direct you to the VA for treatment (which is actually a benefit, not a denial).
Duplicate claim or billing error: Administrative errors by providers can cause improper denials.
Coordination of Benefits (COB) issues: If you have other insurance, TRICARE is typically the secondary payer. COB disputes can cause denials.
Your TRICARE Appeal Rights
TRICARE has a formal, multi-level appeal process:
Level 1: Reconsideration
- File a reconsideration request with your TRICARE regional contractor within 90 days of the denial
- The contractor reviews the claim with additional information you provide
- Contractor must decide within 30 days (clean claims) or notify you of a delay
- Submit your provider's medical records and a supporting letter from your physician
Contact:
- East Region (Humana Military): humanamilitary.com or 1-800-444-5445
- West Region (Health Net/Centene): tricare.mil or 1-844-866-9378
- Overseas (International SOS): tricare.mil/overseas
Level 2: Formal Appeal (Hearing)
If the contractor upholds the denial:
- Request a formal appeal (hearing) through the Defense Health Agency within 60 days of the contractor's reconsideration decision
- You can submit additional documentation and request to present your case in writing or, in some cases, in person
- DHA must decide within 60 days
Level 3: BCDR (Board for Correction of Military Records) — Rarely Applicable
For certain special categories of TRICARE disputes involving military records, the Board for Correction of Military Records (BCMR) has jurisdiction. This is rare and typically for benefit eligibility issues rather than standard claim denials.
Federal Court
After exhausting administrative remedies, you may file a civil action in federal court.
How to Appeal a TRICARE Denial
Step 1: Review Your Explanation of Benefits (EOB)
TRICARE's EOB (called a Summary of Medical Benefits or similar) explains why the claim was denied, citing the specific TRICARE policy. Request the denial in writing if you received only a verbal notification.
Step 2: Review the TRICARE Policy Manual
The TRICARE Policy Manual is publicly available at tricare.mil. Find the section governing your denied service and review the specific coverage criteria. Your appeal must demonstrate that your situation meets these criteria.
Step 3: Gather Supporting Documentation
- Physician's letter: Detailed explanation of medical necessity, your diagnosis, treatment rationale, and response to TRICARE's specific denial reason
- Medical records: Relevant records supporting the diagnosis and treatment
- Referral documentation: If the denial involved a referral dispute, evidence that referral was obtained or that an emergency exception applied
- Prior authorization records: Evidence of any prior authorizations granted
- Specialist letters: For complex medical issues, a letter from a board-certified specialist carries significant weight
Step 4: Submit the Reconsideration Request
Address your reconsideration to your TRICARE regional contractor. Clearly label it as a "TRICARE Reconsideration Request." Include:
- Your TRICARE ID/Social Security number
- The denied claim number(s)
- Your appeal letter
- All supporting documentation
Step 5: Request Formal Appeal from DHA
If the contractor upholds the denial, submit a formal appeal to DHA within 60 days. DHA's formal appeal provides an independent review above the contractor level.
Step 6: Contact Your Military Installation's TRICARE Service Center
If you are near an active duty installation, the TRICARE Service Center (TSC) at the military treatment facility can often assist with appeal navigation, paperwork, and advocacy. This is a free resource for TRICARE beneficiaries.
Step 7: Contact Your Congressional Representative
Members of Congress have casework staff who routinely assist constituents with federal agency issues, including TRICARE. A congressional inquiry can expedite resolution of legitimate TRICARE disputes.
TRICARE and the VA: Understanding Coordination
If you have both TRICARE and VA benefits:
- Service-connected conditions are generally treated by the VA at no cost
- Non-service-connected conditions may be covered by TRICARE
- TRICARE is generally the primary payer when treatment is received from non-VA civilian providers
- The TRICARE and VA Coordination rules are complex — confirm with your TRICARE contractor which agency should be billed for specific services
TRICARE Appeal Timelines
| Action | Timeline |
|---|---|
| Reconsideration request deadline | 90 days from denial |
| Contractor reconsideration decision | 30 days |
| Formal appeal (DHA) request deadline | 60 days from contractor reconsideration decision |
| DHA formal appeal decision | 60 days |
Tips for a Successful TRICARE Appeal
Cite the TRICARE Policy Manual specifically: TRICARE adjudicators evaluate claims against specific manual provisions. An appeal that cites the applicable policy section and argues your case meets the stated criteria is far more persuasive than a general appeal.
Emergency care: TRICARE covers emergency care at any hospital. If the denial involves emergency care, cite TRICARE's emergency care coverage policy. You have additional rights if you were referred to a non-network provider by an emergency room.
Mental health: TRICARE has enhanced mental health benefits, particularly for active duty families. If your mental health claim is denied, review the TRICARE mental health policy and the MHPAEA protections.
Congressional inquiry: Don't underestimate the power of a congressional inquiry for TRICARE issues. Many congressional offices have dedicated military constituent services staff.
Conclusion
TRICARE claim denials are frustrating — especially given the service members and their families that depend on this coverage. But the multi-level appeal process exists precisely to catch wrongful denials. Submit a thorough reconsideration request with strong physician documentation, escalate to DHA if needed, and use your installation's TRICARE Service Center and congressional representative as additional resources. Use ClaimBack at claimback.app to generate a professional appeal letter tailored to TRICARE's coverage criteria.
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