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There are options for your family to reach out to Tricare if you have any issues with medical care received or are hit with an unexpected bill.
Tricare has 4 types of appeals.
Health emergencies can happen at any moment. Typically, things go way too fast for our thought process and there isn’t the luxury to think things through like, “wait, will this decision eventually bite me back with a huge medical bill?” We go to the doctor without question, so ourselves or our loved ones can get treated.
What do we do when that happens?
Your family can file an appeal with Tricare.
How to file an appeal
In Tricare’s words, an appeal is “the action you take if you don’t agree with a decision made about your benefit.” Because it’s particular to decisions, there are separate appeals you can file. Tricare offers 4 different types of appeals: factual, medical necessity, pharmacy and Medicare-Tricare.
Factual appeal: when payment gets denied or stopped for services or supplies that have either been received or authorized already.
Medical necessity appeal: when Tricare denies previous authorization because they assessed that it isn’t medically necessary anymore. The website outlines:
to be medically necessary means it is appropriate, reasonable, and adequate for your condition.
Pharmacy appeal: when your pharmacy prescriptions gets denied when you deem it necessary
Medicare-Tricare appeal: when you qualify for both, you may need to file with Medicare separately with their terms.
With the exception of the Medicare-Tricare appeal, the others require a written letter within 90 days of the decision. Along with that letter, add all your supporting documents that you have and the decision letter itself. For a pharmacy claim, you need to be specific on why you disagree.
The letter needs to be mailed to your contractor’s address (depending on where you are located). Tricare outlines the addresses in this link. You can also take your case a step further by requesting a formal review, reconsideration of decision or an independent hearing, depending on your type of appeal. That’s why I also encourage you to read more about each separate claim on Tricare’s website. That way you can assess your situation better: factual, medical necessity, pharmacy, and Medicare-TRICARE.
There are ways to continue the process when a decision doesn’t come back in your favor.
How to file a grievance
Also, we expect our medical practitioners to be diligent and appropriate when they work. When you are disappointed with your care, there are steps you can take to file a grievance with Tricare, so that your voice is heard.
Similarly to filing an appeal, you must write down your complaint and send it to your Tricare contractor’s address. The letter should outline the description of the event in question (date, time, name of practitioner, location, etc.). I suggest you be as detailed as possible and don’t forget to include any supporting documents.
Also, if you have any issues with dental care with your Tricare Dental plan, that is included too. It’s not limited to situations within medical care facilities.
In addition to your letter, share your sponsor’s Social Security number and all your information as well (name, address, phone number, date of birth, and sign it!). Tricare has a special website for grievances and I urge you to read it here.
If you’re filing an appeal or grievance for a dependent, include all the dependent’s information including your own. It’s good to share more during an appeal or grievance process that way they have the most comprehensive information. The whole family is covered, whether it’s the service member sponsor, spouse and children.
I filed an appeal after Tricare for Life did not cover a Dr’s appointment after I was hospitalized with blood clots in my lungs and legs. When I left the hospital I was given enough Zarelto to last me until the Dr’s appt that the hospital made for me. The Dr’s visit was not covered because they said that followup Dr visits are not covered.. I explained that I was told I had to have Zarelto to prevent further blood clots and that I got a prescription for Zarelto at that Dr visit. I was told that the appeal was final and that I had no other appeals available to me.. Now I ask at every visit if this is a followup visit.