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What Do I Do If I Have a TRICARE Complaint?


TRICARE’s a tremendously valuable benefit. There’s no better bang for the buck in the private health insurance sector. But even though it’s actually administered by contracted insurance carriers, it’s still government health care – with all the massive problems and perverted incentives that entails.

So what can you do if you have a problem?

First, understand whether what you have is an appeal or a grievance. The difference is important, because the TRICARE bureaucracy has different processes for each. If you file an appeal through the grievance channels, or vice versa, you probably won’t get anywhere.

Appeals vs. Grievances

An appeal is the process by which you seek the reversal of a wrong decision by TRICARE officials. That is, if TRICARE denied a benefit or claim that you believe is covered under the terms of your TRICARE agreement, then you would file an appeal.

A grievance, on the other hand, is a complaint about the conduct of TRICARE officials or staff, or how you were treated by the system.

Note the difference: You can be treated extremely professionally and courteously by TRICARE providers and staff throughout the process, even as they wrongly deny a covered benefit.

Similarly, you can be treated very poorly by rude and uncaring staff, even though the coverage decisions made by claims officials were spot-on correct.

Appeals

An appeal may be filed by the beneficiary, a custodial parent, an attorney, a person appointed in writing to represent the beneficiary for the purpose of the appeal, or by an out-of-network participating provider. The latter case will frequently file an appeal for what they believe to be a wrongly-denied reimbursement.

All appeals must be in writing. The mailing address depends on your plan and your location. There are a number of contracted carriers working under the TRICARE banner, so it’s important to route your appeal properly.

You have 90 days to file an appeal. You should receive a response in 30 days or less. However, in some cases, you can request an expedited appeal. You may want to go this route if you are currently seeking treatment and time is of the essence. In this case, you must file the appeal within 3 days. TRICARE has three days to issue its response.

If you are not satisfied with the results of the appeal, you may be able to request a “2nd level” appeal. If that doesn’t work, and the amount at stake is more than $300, you can request a hearing.

For a fuller explanation specific to your plan and location, see your TRICARE Handbook. The TRICARE informational brochure describing the appeals process in greater detail is here. This brochure also includes the addresses for the various regional TRICARE administrators.

If the normal appeals process does not yield satisfactory results, you can also contact your state Office of Insurance Regulation or insurance commissioner. You can get your state contact information here.

Grievances

Grievances are handled at the regional level, by the TRICARE contractor handing patient care for that reason. Like appeals, grievances must be filed in writing. You can find specific criteria and the addresses you must use here.

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