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Guide · the basics · 4 minute read

TRICARE appeals

How to appeal a TRICARE denial. Start with a written reconsideration within 90 days. Next steps differ for factual and medical necessity denials, with dollar minimums at the later levels.

Applies to: Military, veteran or federal employee

Key points

  • Your first appeal is a written reconsideration, mailed (postmarked) within 90 days of the date on the Explanation of Benefits or other decision.
  • Later levels differ for factual denials and medical necessity denials, and dollar minimums of $50 and $300 apply at two of them.
  • Fast appeals exist only for certain medical necessity denials, with a stated deadline of 3 calendar days. Pharmacy denials go to Express Scripts.
  • Check the date on your notice, which controls.
On this page 6

TRICARE is military health coverage. Its appeal process is separate from private insurance and from Medicare, with its own deadlines and its own dollar minimums. The reference page is TRICARE.

What this means

TRICARE splits denials into two kinds, and the second level depends on which you have.

  • A factual denial. TRICARE says a service is not covered, or that you are not eligible, or a similar fact issue.
  • A medical necessity denial. TRICARE says the care is not medically necessary or is not appropriate.

Your Explanation of Benefits or denial letter tells you where to send your appeal. If it does not make clear which kind of denial you have, ask the contractor.

What to do

  1. Look at the date on the Explanation of Benefits or other decision (you). Your first appeal must be in writing and mailed, with a postmark, within 90 days of that date.
  2. Write the reconsideration request and mail it (you). Send it to the contractor named on your letter, and keep a copy and proof of mailing. The contractor normally decides within 60 days.
  3. If you disagree with a factual denial, ask for a formal review (you). It is decided by the Defense Health Agency. The amount in dispute must be $50 or more, and the request must be mailed within 60 days of the reconsideration decision. The formal review is normally decided within 90 days.
  4. If you disagree with a medical necessity denial, ask for a second reconsideration (you). It is handled by the TRICARE Quality Monitoring Contractor, and it must be requested within 90 days of the contractor’s decision. This site has not confirmed the name of the current quality monitoring contractor, so use the name and address in your decision letter.
  5. Last level: an independent hearing (you). The amount in dispute must be $300 or more, and the request must be mailed within 60 days of the formal review or second reconsideration decision. A hearing officer issues a recommended decision. The Director of the Defense Health Agency, or a designee, or the Assistant Secretary of Defense for Health Affairs, issues the final decision.
  6. If waiting could harm you, ask for a fast appeal (you and your doctor). Expedited appeals exist only for medical necessity denials of a continued inpatient stay or of pre-authorization. The regional contractors state a deadline of 3 calendar days from receiving the denial. This site has not found the regulation behind that deadline or the time the contractor has to decide, so call the contractor the same day and ask for both in writing.

Check the date on your notice, which controls.

How the dollar amounts work

The amount in dispute is what TRICARE would pay if the service were covered, not what the provider billed. Claims can be combined to reach the threshold under listed conditions. These amounts are set in the regulation and are not adjusted each year.

The rule

A reconsideration request must be in writing and mailed (postmarked) within 90 days of the date on the Explanation of Benefits or other decision. (Title 32 of the Code of Federal Regulations (CFR), section 199.10(b))

Watch for

  • Medicare and TRICARE together. When Medicare denies a service that both programs cover, the appeal goes to Medicare first. TRICARE appeal rights apply when TRICARE, and not Medicare, would pay. See Original Medicare: the five appeal levels.
  • Who can appeal. A provider that does not accept TRICARE assignment on the claim is not a party and cannot appeal. You, the beneficiary, can.
  • Pharmacy denials. Appeal to Express Scripts within 90 days of the decision.
  • Who your contractor is. In 2026, the East Region contractor is Humana Military, and the West Region contractor is TriWest Healthcare Alliance. Overseas it is International SOS. TRICARE For Life, which works with Medicare, is handled by Wisconsin Physicians Service, and pharmacy by Express Scripts. This site has not verified when the current contracts started or which states moved between regions, so use the address on your decision letter.
  • Older agency names. The regulation still uses older agency names, so its wording may not match today’s.

What next

Sources

Official and primary sources used on this page. Checked 2026-11-12.

  1. 32 CFR 199.10, appeal and hearing procedures — Electronic Code of Federal Regulations
  2. 32 CFR 199.15, quality and utilization review peer review organization program — Electronic Code of Federal Regulations
  3. TRICARE appeals — TRICARE, Defense Health Agency
  4. TRICARE East Region, appeals and grievances — TRICARE, Defense Health Agency
  5. TRICARE West Region, authorization appeals — TRICARE, Defense Health Agency
  6. TRICARE regions — TRICARE, Defense Health Agency

What next

Letters and scripts

  • Letter or script

    Ask for your claim file

    A written request for everything the plan used or created when it decided your claim, sent before you appeal. It asks for the file free of charge and says clearly that it is not an appeal.

  • Letter or script

    Request an expedited appeal

    Asks your plan to decide an appeal as an urgent claim, within 72 hours, because waiting could seriously harm your health, and to contact your doctor.

  • Letter or script

    Name someone to act for you

    A plain written statement naming a family member, friend or advocate to speak and write to your health plan for you about a claim or appeal. It does not replace the plan's own form.

Checklists

  • Checklist

    Expedited appeal

    How to ask your plan for a fast decision when waiting could seriously harm your health, and what to do if it says no.

Related guides

  • Guide

    Veterans Affairs health care and community care denials

    Veterans Affairs uses two different routes for health care disputes: a clinical appeal for treatment decisions and a decision review for benefit and payment decisions. Pick the right one first.

  • Guide

    Federal employee plan appeals

    How to appeal a Federal Employees Health Benefits plan denial. Ask the carrier to reconsider within 6 months. Then ask the Office of Personnel Management to review. We also explain what a lawsuit looks like.

  • Guide

    Original Medicare: the five appeal levels

    A plain walk through the five levels of a Medicare Parts A and B appeal. It starts from the Medicare Summary Notice. It names the deadlines that trip people up and what to do first.

  • Guide

    How to get an expedited appeal

    When waiting could seriously harm your health, you can ask for a fast appeal, decided in 72 hours or less, and ask for independent review at the same time. Here is how to ask and what your doctor can do.

  • Guide

    How to request your claim file

    Ask your plan in writing, before you appeal, for everything it used to decide your claim. Covers what to ask for, where to send it, what the rules say about cost and timing, and what to do if the plan stalls.

  • Guide

    Acting for someone else

    You can usually help a parent, partner or adult child with a denial if they give written permission. Here is how to name a representative with plans, Medicare and Medicaid, and what this page does not cover.

This page is general information, not legal or medical advice. Your notice, your plan document and the law that applies to your coverage control.

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