Who can appeal against insurance denial claims

Proper Appealing Parties

•     The TRICARE beneficiary (including minors)

•     The non-network participating (accepts  assignment) provider of services

•     A non-network participating (accepts assignment) provider appealing a readmission/preprocedure denial (when services have not been rendered)

•     A provider who has been denied approval as a TRICARE-authorized provider or who has been terminated, excluded, suspended, or otherwise sanctioned

•     A person who has been appointed in writing by the beneficiary to represent them in the appeal

•     An attorney filing on behalf of a beneficiary

•     A custodial parent or guardian of a beneficiary under 18 years of age To avoid possible conflict of interest, an officer or employee of the U.S. Government, such a an employee or member of the uniformed services (including an employee or staff member of a uniformed services legal office), or a Beneficiary Counseling and Assistance Coordinator, subject to exceptions in Title 18, United States Code, Section 205, is not eligible to serve as a representative unless the beneficiary is an immediate family member.

Appeal Filing Deadlines

An appeal must be filed before the expiration of the appeal filing deadline or within 20 calendar days of the date of the contractor’s letter of notification of an improper appealing party filing. The letter of notification includes information for providers to submit these appeals. There must be a denial of an appeal due to untimely filing before an extension can be considered.