TRICAREPayer appeals · Defense Health Agency (military health program)

How to appeal a TRICARE denial

TRICARE, the military health program, runs its own appeal process — and the first deadline is short: 90 days from the decision to file. The levels and the dollar thresholds are set by federal regulation, not by a private plan.

A TRICARE denial is appealed through a defined process under 32 CFR 199.10: a reconsideration by the regional contractor, a formal review by the agency, and — for disputes at or above a dollar threshold — an independent hearing. Medical-necessity and factual denials follow this path, and the initial appeal generally must be filed within 90 days of the decision.

How appeals work at TRICARE

TRICARE appeals run under 32 CFR 199.10. The initial appeal (a reconsideration by the regional contractor) is generally due within 90 days of the date on the explanation of benefits or decision. If the disputed amount is less than $300, the reconsideration decision is final; if it is $300 or more, you can request an independent hearing, generally within 60 days of the formal-review decision. Medical-necessity appeals and factual appeals follow distinct tracks within this framework. Confirm the exact deadline on the decision you received.

What TRICARE commonly denies

  • Medical necessity for a procedure, service, or drug.
  • Factual denials — coverage, eligibility, or a coding determination.
  • Prior authorization or referral requirements not met.
  • A service treated as not covered under the program rules.

Is a TRICARE denial worth appealing?

Sometimes worth appealing

Worth appealing medical-necessity and factual denials within the program’s framework — but watch the 90-day clock, which is shorter than commercial plans’ 180 days. For a medical-necessity denial, document the clinical record against the coverage rule; for a factual denial, supply the missing eligibility or coverage proof. The independent hearing is available only when the disputed amount is at least $300.

How to appeal a TRICARE denial

  1. 1

    File within 90 days

    Submit the reconsideration within 90 days of the explanation of benefits or decision date — a short window relative to commercial plans.

  2. 2

    Match the track to the denial

    Use the medical-necessity track for clinical denials and the factual track for coverage, eligibility, or coding determinations.

  3. 3

    Escalate if the amount qualifies

    If the dispute is $300 or more, you can request an independent hearing after the formal review, generally within 60 days of that decision.

TRICARE — frequently asked

How long do I have to appeal a TRICARE denial?
Generally 90 days from the date on the explanation of benefits or decision to file the initial appeal (reconsideration), under 32 CFR 199.10. Confirm the exact date on your notice.
Can I always get a TRICARE hearing?
No. An independent hearing is available only when the disputed amount is at least $300. Below that, the reconsideration decision is final.

Related guides

CO-50 · medical necessityMedical-necessity letterCO-197 · auth absent

Sources

Appeal timeframes and venues are summarized from the federal ERISA/ACA and Medicare Advantage frameworks and vary by plan; payer-specific deadlines and addresses are on your denial notice. Medicare Advantage figures are from KFF's 2024 analysis. This is general information, not legal or coverage advice — confirm the deadline and process on the notice and the plan documents.

When the appeal has to be written, and cited

Upload the denied EOB and Merits returns a complete, citation-verified appeal letter — the clinical argument, the payer's own coverage criteria, and your federal appeal rights — in about a minute.

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