TRICARE denied your claim: how to appeal
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).
If TRICARE denied a claim or service, 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.
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. |
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.
Patterns we see on TRICARE denials
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.
Contractor reconsideration, formal review by DHA, then independent hearing (above the amount-in-controversy threshold), then DHA Director final decision.
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.
How we file TRICARE appeals
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.
TRICARE denials: the questions people ask
How long do I have to appeal a TRICARE denial?
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. Count from the date on the denial letter, not the date you opened it.
Where do I send a TRICARE appeal?
The appeal address, fax number or portal for your specific plan is printed on your denial letter, usually under a heading like "Your right to appeal" or "How to request a review". We deliberately do not publish one address per carrier: TRICARE routes appeals differently by employer group, region, product line and appeal level, and sending it to the wrong place can cost you the deadline. If the letter does not state where to send it, that omission is itself worth raising in the appeal, and the member number on your card reaches someone who must tell you.
What should a TRICARE appeal letter include?
The member and claim numbers, the exact denial reason quoted from the letter, the clinical records that answer that specific reason, and a request in writing for the criteria the decision was based on and a copy of the claim file. Appeals succeed on what you attach more than on how strongly you argue, because the first reviewer often never saw the full chart.
What happens if TRICARE denies the appeal again?
Contractor reconsideration, formal review by DHA, then independent hearing (above the amount-in-controversy threshold), then DHA Director final decision. After a final internal denial, external review by an independent organisation is a separate lane, it is free to you, and the decision binds the plan. Which external review applies depends on whether your plan is employer self-funded, state-regulated, Medicare or Medicaid.
TRICARE appeal guides by denial type
What TRICARE tends to cite for each kind of denial, the rule that controls it, and what the appeal has to say.
- TRICARE surgery denials
- TRICARE imaging denials
- TRICARE medication denials
- TRICARE medicare denials
- TRICARE prior auth denials
- TRICARE experimental denials
- TRICARE mh parity denials
- TRICARE oon emergency denials
- TRICARE infertility / ivf denials
- TRICARE gender-affirming denials
- TRICARE transplant denials
- TRICARE level of care denials
- TRICARE air ambulance denials
- TRICARE step therapy denials
Denied by TRICARE? Let's appeal it.
Two-minute micro intake. We confirm fit and reply within one business day. No card at intake. You only pay if the carrier reverses the denial.
Start Your AppealDisclaimer: information shown is general guidance, not legal advice or a guarantee of outcome. Individual case outcomes depend on documentation, timing, and the specific terms of your plan.