Filing an Appeal or Grievance
If you disagree with certain decisions made by TRICARE or TriWest regarding your benefits, you have the right to appeal that decision.
There are specific benefit issues that are appealable and the appeal process varies depending on the type of benefit issue.
For issues that can't be appealed, a
grievance process is available, which allows you to
submit your concern or complaint in writing.
Appeals
Only the beneficiary, the beneficiary’s appointed representative, a participating or sanctioned non-network provider, the
parent of an underage child, or the guardian of a beneficiary who is not competent to act in his or her own behalf can file an appeal.
You may appeal a decision on behalf of your spouse as long as your spouse has appointed you in writing as his or her representative.
You can download a copy of the
Appointment of Representative for Appeal and Authorization to Disclose Information Form from www.triwest.com.
In all cases, the appealing party must prove that he or she is entitled to TRICARE benefits. While you cannot appeal the amount
TriWest determines to be the allowable charge for a particular medical service, you may ask TriWest to review the amount of the allowable
charge to determine if it was calculated correctly.
To appeal a decision made by a Military Treatment Facility (MTF), check with the MTF’s
Beneficiary Counseling and Assistance Coordinator (BCAC)
to find out their local appeals process.
To appeal a claims decision, submit your appeal within 90 days after the date on the Claim Summary in writing to:
TriWest Healthcare Alliance
Claims Appeals
P.O. Box 86508
Phoenix, AZ 85080
Submit prior authorization appeals to:
TriWest Healthcare Alliance
Reconsideration Department
P.O. Box 86508
Phoenix, AZ 85080
Prior authorization denial appeals may be either
expedited or
non-expedited.
Expedited
An expedited appeal or reconsideration must meet all the following criteria:
- It must be for a medical necessity denial
- It must be for care not yet received
- It must be filed by you or an appointed representative
- It must be filed within three calendar days after you receive the initial denial.
TriWest will process the appeal and give your provider a verbal determination within 72 hours.
Non-Expedited
A non-expedited appeal or reconsideration must be filed no later than 90 days after the date on the initial denial. In this case, TriWest
will issue a determination letter indicating the decision and any further rights you may have.
Inpatient Concurrent Review Denials
If you are an inpatient within a facility and care has been denied, your appeal should be submitted by noon the day after you receive
the denial in order for it to be expedited. TriWest will, however, receive requests up to 90 days after the initial denial. These requests
will not be treated as expedited.
The appeal process itself varies depending on whether the denial of benefits involves a medical-necessity determination or a factual
determination. All initial and appeal denial determinations include a section that fully explains how, where, and by when you must file
the next level of appeal. Contact TriWest at 1-888-TRIWEST (874 9378) for more information.
Grievances
Grievance
details
Any TRICARE beneficiary may file a grievance, which is a written complaint or concern about a non-appealable issue regarding a perceived
failure by any member of the healthcare delivery team.
Submit all grievances to:
TriWest Healthcare Alliance
Attn.: Customer Relations Dept.
P.O. Box 42049
Phoenix, AZ 85080
Please include the following information:
- Your name, address, telephone number and date of birth
- Sponsor's Social Security number
- Your signature
- A description of the issue or concern that must include:
- Date and time of event
- Name of provider(s) and person(s) involved
- Event location (address)
- Nature of the concern or complaint
- Details describing the event or issue
- Any appropriate supporting documents.
