TRICARE medicare denied: how to appeal

Quick answer

If TRICARE denied your medicare, you can appeal, and the plan must give you its file and the criteria it used. You have 90 days from the notice (TRICARE) to file. The date printed on your denial notice controls; it can only be later than these floors, never earlier.

Why TRICARE denies medicare

TRICARE is the U.S. Department of Defense health program covering active-duty servicemembers, retirees, and eligible family members. Appeals are governed by 32 CFR Part 199, administered by regional contractors (Humana Military and TriWest), with final review by the Defense Health Agency (DHA).

For medicare specifically: Medicare denials follow a federally-defined 5-level appeal process. Most beneficiaries stop at level 1. The higher levels, particularly the Independent Review Entity and ALJ, reverse a meaningful share of cases.

The law that controls this appeal

Coverage must track Traditional Medicare (NCDs and LCDs); CMS rule CMS-4201-F (2024) bars algorithm-only denials, resolved through the federal five-level appeal ladder.

Note for TRICARE: where the standard above cites ERISA or the ACA appeal rules, those describe employer and Marketplace plans. The windows and levels that apply to TRICARE are in the table below.

At a glance

TRICARE appeals: the rule, the deadline and the next level, by plan type

TRICARE is a federal programme with its own appeal rules. State external review, ERISA and the ACA appeal rules do not apply.

Plan type	Rule that governs	File your appeal within	The plan must answer	If the plan says no again
TRICARE Active-duty families, retirees and their families. Claims are handled by Humana Military (East) or TriWest (West) under the Defense Health Agency.	32 CFR 199.10 (appeal and hearing procedures) and the TRICARE Operations Manual, Chapter 12. ERISA, the ACA appeal rules and state external review do not apply.	Reconsideration: 90 days from the date of the notice of the initial determination. Formal review by the Defense Health Agency: 60 days from the reconsideration decision. Hearing: 60 days from the formal-review decision (32 CFR 199.10).	Expedited review is available for pre-admission and pre-authorization denials; the contractor's clock for a standard reconsideration is stated in the letter.	Formal review by the DHA, an independent hearing when the amount in controversy meets the threshold in 32 CFR 199.10(d), and a final decision by the DHA Director.

TRICARE

What you can demand. The sponsor, the beneficiary, a participating provider or an appointed representative can appeal. Ask the contractor for the file and the medical-necessity criteria it applied.

How to open the appeal. Cite 32 CFR 199.10 and the benefit rule in 32 CFR 199.4: state the appeal type, address it to the regional contractor named on the letter, and request the criteria used.

Primary sources for this table

Windows are federal floors or the rule as written; the denial notice controls. Reviewed 13 September 2026. General information, not legal advice; Apellica is not a law firm.

What TRICARE denies for medicare

The medicare services most often denied:

Skilled nursing facility (SNF) coverage
Home health services
Durable medical equipment (hospital beds, oxygen, mobility)
Hospice eligibility
Inpatient vs. observation status
Part D drug coverage (separate ladder)

Why medicare claims get denied

A typical TRICARE medicare denial almost always cites one of these reasons. Each one maps to a specific rebuttal in the appeal:

Plan claims criteria for SNF / home-health not met
DME deemed 'not medically necessary' or 'convenience'
Inpatient stay reclassified as observation (lower coverage)
Drug not on plan formulary or step therapy required

The TRICARE appeal process

Appeal levels: Contractor reconsideration, formal review by DHA, then independent hearing (above the amount-in-controversy threshold), then DHA Director final decision.

Carrier timing: 90 days from denial for reconsideration; 60 days from each subsequent adverse decision for the next level. Urgent / pre-authorization timelines compress to 72 hours.

Medicare timing for TRICARE: the filing windows and decision clocks in the table above apply; the date on the notice controls.

What we know about TRICARE: TRICARE rules are federal, state DOI external review does not apply. We brief appeals against 32 CFR Part 199 and the TRICARE Operations Manual specifically.

Common TRICARE denial patterns for medicare

Regional contractor reconsideration first. TRICARE appeals begin with reconsideration by the regional managed care support contractor, Humana Military (East) or TriWest (West). The reconsideration request must be in writing and is typically due within 90 days of the initial denial.
Formal review by DHA. After contractor reconsideration, members can request a formal review by the Defense Health Agency. This step is the gateway to a hearing and is the prerequisite to any further federal review.
Independent hearing for higher-dollar cases. TRICARE provides an independent hearing for appeals meeting a minimum amount-in-controversy threshold. The hearing officer's recommendation goes to the DHA Director for a final agency decision.

How to win your TRICARE medicare appeal

Strategy for medicare: File at level 1 within 60 days. Begin level-2 paperwork immediately on receipt of level-1 denial. The ALJ level (level 3) is where the most complex reversals happen, Medicare provides a federal judge to hear the case by phone.

Filed against TRICARE, that strategy rides on this procedural spine:

Procedural-rights anchor. Cite 32 CFR 199.10 and the benefit rule in 32 CFR 199.4: state the appeal type, address it to the regional contractor named on the letter, and request the criteria used.
Criteria-disclosure demand. TRICARE frequently denies on "not medically necessary" without disclosing the clinical criteria applied. Once disclosed, those criteria become the rebuttal map.
Controlling-standard citation. Coverage must track Traditional Medicare (NCDs and LCDs); CMS rule CMS-4201-F (2024) bars algorithm-only denials, resolved through the federal five-level appeal ladder.
Treating-provider attestation. A letter from the treating physician addressing each criterion in TRICARE's own policy language. This is the single strongest evidentiary element.
Requested action. A specific demand to reverse the medicare denial and approve the service, not a general "please reconsider."

Documents you'll need for your TRICARE medicare appeal

Denial / determination letter
Medicare card
CMS-1696 Appointment of Representative form (we provide)
Treating physician's records
Care plan or facility records

What a medicare appeal can recover

Typical recovery for medicare cases runs $1,000 - $100,000+. The exact figure depends on the specific service and your plan's contracted rates.

TRICARE medicare appeals: frequently asked questions

How do I appeal your TRICARE Medicare denial?

Medicare denials follow a federal five-level appeal process. File level 1 within 60 days, and begin level-2 paperwork the moment the level-1 denial arrives. The Independent Review Entity and the ALJ levels reverse a meaningful share of cases.

What is the deadline for each Medicare appeal level?

You generally have 60 days between each level. The level-3 ALJ hearing requires the case value to exceed roughly $200, and multiple denials can be consolidated to meet that threshold.

Why was my SNF, home health, or DME denied?

Plans deny when they claim the skilled-nursing or home-health criteria are not met, when equipment is deemed convenience rather than medically necessary, or when an inpatient stay is reclassified as observation. Coverage must track Traditional Medicare's national and local coverage determinations.

Does an algorithm decide TRICARE Medicare Advantage denials?

It cannot be the sole basis. CMS rule CMS-4201-F (2024) prohibits algorithm-only coverage denials in Medicare Advantage; a denial that relies on a data model instead of your individual record is non-compliant and appealable on that ground.

What Apellica does for TRICARE medicare appeals

We file appeals against TRICARE specifically configured to its internal review process. Every medicare appeal embeds the criteria-disclosure demand, the procedural-rights anchor, the controlling-standard citation above, treating-provider attestation language, and the peer-reviewed evidence relevant to the denied service.

Cost: $0 upfront. We work on contingency for TRICARE appeals, if the appeal succeeds, we collect a percentage of the recovered claim value. If it fails, you owe nothing.

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TRICARE denied your medicare? Here is what to do next