Your coverage
Military, veteran and federal employee coverage
TRICARE, Veterans Affairs health care, federal employee plans and the Indian Health Service.
Do this today
- Find the kind of plan you have Pick the closest match below. Each page has the appeal steps, deadlines and free help for it.
- Read: Federal employee plan appeals 4 minute read. 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.
-
Put this step on My Plan
So you can come back to it, and keep your dates and calls in one place.
In brief
- Step one is a written request to your plan's carrier to reconsider, within 6 months of the date of the denial notice. The carrier has 30 days to answer.
- Step two is a request to the Office of Personnel Management (OPM), usually within 90 days of the carrier's letter upholding the denial.
- If OPM finds you are entitled to the benefit, the carrier must pay or provide it. A lawsuit goes against OPM, not the carrier, and only after both steps.
- Check the date on your notice, which controls.
Coverage types in this group
Each page has the appeal steps, deadlines and free help for that coverage.
- TRICARE
Military health coverage. Your first appeal is a written reconsideration, mailed within 90 days of the date on your Explanation of Benefits. The next steps depend on whether the denial is about the facts or about medical necessity.
- Veterans Affairs health care
Two separate tracks. A disagreement with a medical treatment decision goes through a clinical appeal. A disagreement with a health care benefit decision, such as payment, goes through decision review within one year.
- Federal Employees Health Benefits plan
Coverage for federal workers through a private carrier. Ask your carrier in writing to reconsider within 6 months of the date on the denial notice. If the carrier says no again, the Office of Personnel Management reviews it.
- Indian Health Service Purchased/Referred Care
Indian Health Service money for care from outside providers. It is not an entitlement, and a referral does not mean the bill will be paid. Each of the three appeal steps has a 30-day deadline from receiving the notice.
More guides, tools and letters
More guides, tools, letters 7
Guides
- 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.
- 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.
- 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.
Programs and services
- Program or service
Indian Health Service Purchased/Referred Care: appeal a denial
How American Indian and Alaska Native patients ask the Indian Health Service to reconsider a denial of payment for care received away from an Indian Health Service or tribal facility.
From Indian Health Service
- Program or service
Office of Personnel Management: disputed claims for federal employee health plans
The Office of Personnel Management (OPM) reviews a denied claim from a federal employee health plan after the plan has reconsidered it. This page explains the order, how to write to OPM, and the response times it states.
From U.S. Office of Personnel Management
- Program or service
TRICARE appeals
The official TRICARE page on the four kinds of appeal (factual, medical necessity, pharmacy, and Medicare-TRICARE), with mailing addresses for each regional contractor and the Defense Health Agency.
From TRICARE (Defense Health Agency)
- Program or service
Veterans Affairs clinical appeals and decision reviews
How a veteran asks Veterans Affairs (VA) to review a treatment decision (a clinical appeal) or a decision about a VA benefit, including health care benefits, with the review options and what to send.
From U.S. Department of Veterans Affairs
Questions to keep handy
- What exactly was denied, and under which part of the plan?
- What is my deadline, and what is it counted from?
- Where and how do I send my request, and how will I prove it arrived?
- Who decides, and can I ask for a faster decision?
Not what you need? Find a person who can help, or search the whole site.