Reconsiderations and Appeals

Providers can submit a claim review request for reconsideration when they need to dispute the outcome of a processed claim.

Examples of issues that may need secondary review include:

  • Allowed amount disputes.
  • OHI issues.
  • Timely filing denials.
  • Penalties for no authorization.
  • Denial code(s).

Download the Provider Claims Reconsideration form and mail or fax to the address below. Please include all supporting documentation relevant to the review request. A claim reconsideration must be submitted no later than 90 days from the date of the remittance.

TRICARE West Correspondence
P.O. Box 2748
Virginia Beach, VA 23450
Fax: 1-866-852-1969

There are a few issues that are appealable:

  • Claims denied due to TRICARE policy limitations.
  • Claims denied as not medically necessary.
  • Claims processed as POS only when the reason for dispute is that the service was for emergency care.

Only the following individuals may file an appeal:

  • The beneficiary (including minors).
  • The parent or guardian representing a minor or beneficiary.
  • The non-network participating provider of services.
  • A representative appointed by the proper appealing party (Must be in writing and be signed by the proper appealing party, or the representative must be court-appointed).

All appeal requests must be in writing and signed by the appealing party or the appealing party’s representative. The appeal request must state the issue in dispute. A copy of the initial denial (EOB/provider remittance advice) and any additional documentation in support of the appeal should be submitted with the request. An appeal request must be received within 90 days of the date on the remittance advice.

Providers should mail or fax appeal requests to:

TRICARE West Claims Appeals
P.O. Box 2777
Virginia Beach, VA 23450
Fax: 1-866-670-4330