Filing an Appeal or Grievance

If you disagree with certain decisions made by TRICARE or TriWest regarding your benefits, you have the right to appeal that decision. There are specific benefit issues that are appealable and the appeal process varies depending on the type of benefit issue.

For issues that can't be appealed, a grievance process is available, which allows you to submit your concern or complaint in writing.

Appeals

• Appealable Issues
• Requirements
• Medical Necessity Appeals Process
• Factual Appeals Process

To appeal a claims decision, submit your appeal within 90 days after the date on the EOB in writing to:

TriWest Healthcare Alliance
Claims Appeals
P.O. Box 86508
Phoenix, AZ 85080

Submit prior authorization appeals to:

TriWest Healthcare Alliance
Claims Appeals
P.O. Box 86508
Phoenix, AZ 85080

Prior authorization denial appeals may be either expedited or non-expedited, depending on the urgency of the situation.

An expedited review must be filed by you or an appointed representative within three calendar days after your receipt of the initial denial, and will be processed within three working days by TriWest. Expedited review of a prior authorization denial applies only to denials based on medical necessity when the requested care has not yet been received.

A non-expedited review must be filed no later than 90 days after the date on the initial denial. In this case, TriWest will issue a determination letter indicating the decision and any further rights you may have.

Grievances

Any TRICARE beneficiary may file a grievance, which is a written complaint or concern about a non-appealable issue regarding a perceived failure by any member of the health care delivery team.

Grievance details

Submit all grievances to:

TriWest Healthcare Alliance
Attn.: Customer Relations Dept.
P.O. Box 86036
Phoenix, AZ 85080

Please include the following information:

• Your name, address, telephone number and date of birth
• Sponsor's Social Security number
• Your signature
• A description of the issue or concern that must include:
  • Date and time of event
  • Name of provider(s) and person(s) involved
  • Event location (address)
  • Nature of the concern or complaint
  • Details describing the event or issue
  • Any appropriate supporting documents