TRICARE (military and dependents)
TRICARE covers active duty service members, retirees, and their families. Appeals are governed by 32 CFR §199.10 with TRICARE-specific timelines and a tiered review pathway through the contractor, the Defense Health Agency, and (in some cases) the courts.
What this plan type is
TRICARE is the DOD health-care program for active duty service members (ADSMs), retirees, and their dependents. Major plan options: TRICARE Prime (HMO-style, PCM-coordinated), TRICARE Select (PPO-style fee-for-service), TRICARE For Life (Medicare wrap for retirees 65+), TRICARE Young Adult (dependents 21-26). Administered regionally by contractors (Humana Military East, TriWest West) under DHA oversight.
Your appeal rights
32 CFR §199.10 governs TRICARE appeals. Two main categories: (1) factual appeals (claim payment), filed within 90 days; (2) authorisation appeals (medical necessity), filed within 90 days. First-level review by the contractor, second-level by DHA. ADSMs and dependents can also raise issues through their installation's Patient Advocate or via Inspector General channels.
Common denial patterns
- Not medically necessary per TRICARE criteria
- Not authorised by PCM (TRICARE Prime)
- Excluded benefit per 32 CFR §199.4 (e.g., custodial care)
- Outside referral area for TRICARE Prime
What's unique about this plan type
- Patient Advocate available at every military medical facility
- DHA review at second level — federal employee adjudication
- TRICARE For Life pays after Medicare — claims auto-cross over
- ADSMs are covered everywhere — line-of-duty determination if injured off-duty
Frequently asked questions
What is a TRICARE (military and dependents)?
TRICARE is the DOD health-care program for active duty service members (ADSMs), retirees, and their dependents. Major plan options: TRICARE Prime (HMO-style, PCM-coordinated), TRICARE Select (PPO-style fee-for-service), TRICARE For Life (Medicare wrap for retirees 65+), TRICARE Young Adult (dependents 21-26). Administered regionally by contractors (Humana Military East, TriWest West) under DHA oversight.
What appeal rights does a TRICARE (military and dependents) member have?
32 CFR §199.10 governs TRICARE appeals. Two main categories: (1) factual appeals (claim payment), filed within 90 days; (2) authorisation appeals (medical necessity), filed within 90 days. First-level review by the contractor, second-level by DHA. ADSMs and dependents can also raise issues through their installation's Patient Advocate or via Inspector General channels.
What's unique about a TRICARE (military and dependents)?
Patient Advocate available at every military medical facility DHA review at second level — federal employee adjudication TRICARE For Life pays after Medicare — claims auto-cross over ADSMs are covered everywhere — line-of-duty determination if injured off-duty
Other plan types
- MHPAEAParity for MH/SUD applies to TRICARE
- ACA Marketplace (individual / family) planIndividual and family plans purchased through Healthcare.gov or a state-based exchange. Appeal right
- Employer-sponsored fully-insured planAbout 35% of employer-covered Americans are on fully-insured employer plans — the employer pays prem
- ERISA self-funded employer planAbout 65% of employer-covered Americans are on a self-funded ERISA plan. The employer (or a TPA) bea
- FEHB (federal employees + retirees)The Federal Employees Health Benefits Program covers ~8 million federal employees, retirees, and dep
Sources
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