Appealing Tricare’s denial for mammogram
July 7th, 2010 | TriCare Help | Posted by Military Times
Q. I am 33 and currently have Tricare Standard and Extra. For the past two years, my mammogram claims have been denied. My mother was diagnosed with breast cancer at 32. Every doctor recommends screening 5 years before your closest family member’s diagnosis, or at 35, whichever comes first. Tricare sees the 35 as the magic number, even though this overlooks the premenepausal women who do get cancer.
My doctors and I have tried to appeal and lost because Tricare will only look at the claim initially based on policy limitations not on best medical practices. They won’t even look at it beyond the whole “not 35″ guideline because Tricare would only pay $39. So we are stuck with a sizable bill each year. Is there any other appeal channel out there or are we left holding the bill each year?
All Tricare operations including eligibility, covered and noncovered medical services, amounts and methods of payments, and appeals are governed by federal law and regulation
Anytime a Tricare claim, or a request for a limited service, is denied, Tricare has a formal, legal, process for appealing an adverse decision. It is called a Request for Reconsideration.
An appeal must be in writing. It must state the specific matter in dispute. It should include any pertinent information about the matter in dispute that was not submitted previously. It must include a copy of the Tricare Explanation of Benefits (EOB) or letter reporting the denial of coverage or payment, and it must be sent to the Tricare claims processing office that issued the denial of coverage or payment (EOB) within 90 days after the denial was issued.
Tricare will send you a formal report of the result of your appeal after your original claim was reviewed by Tricare’s medical staff or, if appropriate, its independent, outside, medical consultant. The report will discuss with you the specific reason for the denial and, if appropriate, any additional avenues of appeal that are available to you.
If you did not receive such a report, it is possible that what you submitted was not in compliance with the formal rules for filing an appeal. Those rules are published on the back of every Tricare Explanation of Benefits.
To resolve this issue, you need more help than I can provide. Please send a detailed report of your problem to Tricare Management Activity, 16401 E. Centretech Parkway, Aurora, CO 80011-90343. Please include your full name and your sponsor’s Social Security number, a telephone number where you can be reached during the day, and copies of all pertinent documents including correspondence with Tricare. Although it may not be necessary, it could be of help to include your doctor’s name, address, and telephone number.
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