Provider Disputes or Appeals

Provider Disputes

A dispute is the first formal review of the processing of a claim by TRICARE Prime® Demo by CareSource Military & Veterans™ (excluding denials based on medical necessity) and is typically submitted by participating providers prior to claim appeal. You can submit a claim payment dispute when you disagree with payment and any other post-service claim denial.

Mail submissions are only accepted if the attachment is greater than 100 MB and not able to be submitted through the portal.

Claim Appeals

If you do not agree with a denial on a processed claim, you have 90 calendar days from the date of service or discharge, unless otherwise specified in your contract, to submit an appeal.

If you do not submit an appeal in the required time frame, we will not reconsider the claim, and the appeal will be dismissed. You will receive notification in writing of the appeal decision. If your appeal is approved, your payment will appear on the Explanation of Payment (EOP).

Clinical Appeals

A clinical appeal is a written request by a provider to review a prior authorization denial with a clinical decision regarding medical necessity. Clinical denials are issued from CareSource Military & Veterans (CSMV) Utilization Management. You may submit clinical appeals pre- or post-service.

An appeal of a clinical determination may be submitted in writing by:

• The beneficiary;
• A non-network participating provider of care; or
• An appointed representative acting on behalf of the beneficiary or provider.

Expedited Appeals

Only the beneficiary or their appointed representative may request an expedited (urgent) appeal.

Peer-to-Peer Review

CSMV peer-to-peer review is a process where a beneficiary’s treating physician discusses a case with a CSMV medical expert. This review is typically requested when there is a disagreement about the medical necessity or appropriateness of a proposed treatment or service.

• Medical Necessity Disputes: If CSMV denies coverage for a service or treatment, citing medical necessity concerns, a peer-to-peer review can be requested.
• Treatment Plan Disagreements: When there’s a difference of opinion between the treating physician and CSMV regarding the best course of treatment.

1. 1
   Request: The beneficiary or their treating physician initiates the request for a peer-to-peer review. This is usually done in writing, outlining the specific concerns and reasons for the request.
2. 2
   CSMV Review: CSMV reviews the request and determines if a peer-to-peer review is warranted.
3. 3
   Peer Selection: If approved, we select a medical expert in the relevant field to participate in the review.
4. 4
   The Review: The treating physician and the CSMV medical expert discuss the case, sharing medical information and treatment plans. The goal is to reach a mutual understanding and agreement on the best course of action.
5. 5
   Decision: Following the discussion, we issue a decision regarding the disputed treatment or service. This decision can be to approve, deny, or modify the original decision.

• Time Frame: CSMV aims to complete the peer-to-peer review process within a specific timeframe, typically within a few business days.
• Documentation: It’s crucial to have detailed medical records and supporting documentation to present during the review.
• Beneficiary Involvement: While the review is primarily between the physicians, beneficiaries may be involved to provide additional information or clarify questions.
• Appeal Rights: If the outcome of the peer-to-peer review is unsatisfactory, beneficiaries may have the option to appeal the decision through our appeals process.

Additional Information: We can provide specific guidance and assistance with the peer-to-peer review process and the TRICARE website provides detailed information about the appeals process, including peer-to-peer reviews.

After receiving a letter from TRICARE Prime Demo denying coverage, a provider or beneficiary can submit a pre-service or post-service clinical appeal. Clinical appeals are reviewed by nurses and physicians not involved in any prior review. They are also reviewed by practitioners with expertise and knowledge appropriate to the item, service, or drug being requested. Refer to the provider manual for further information related to clinical appeals submission.

How to Submit Appeals

The most efficient way to submit appeals is through our provider portal. Other options include submitting a Standard Appeal Form (coming soon) or an Expedited Appeal Form (coming soon).

Include the following required documentation:

• Progress notes including symptoms and their duration, physical exam findings, conservative treatment that the beneficiary has completed, preliminary procedures already completed and the reason service is being requested
• Any documentation of specialists’ reports or evaluations, any pertinent previous diagnostic reports and therapy notes
• If the service has already been provided, a copy of the original remittance advice and/or the denied claim
• If filing an appeal on behalf of a beneficiary or for pre-service issues, the beneficiary’s written consent (or signed Appointment of Representative form (coming soon) for dual benefit beneficiaries), which must be specific to the service being appealed, is only valid for that appeal and must be signed by the beneficiary (Please note: You can use the Consent for Provider to File an Appeal on Patient/Beneficiary’s Behalf form (coming soon) to record this consent.)

Expediting Clinical Appeals

A request for an expedited reconsideration of a preadmission or preprocedural denial must be filed by the beneficiary or their representative in writing within three calendar days after the date of the receipt of the initial denial determination. The date of receipt of the request for reconsideration is considered to be five calendar days after the date of the initial denial determination, unless the receipt date is documented. Requests received outside of this timeframe will be treated as non-expedited appeals.

Please see “Denied Expedited Appeals” for more information about what happens if a request for expedited appeal review is denied, and “Extending an Appeal” for more information about extensions.

Please note, there is a limited amount of time to submit additional information for expedited clinical appeals. TRICARE Prime Demo will outreach to the beneficiary within one business day about any information needed to evaluate the expedited appeal and will outreach and work with the provider to obtain any needed information for the expedited appeal.

Notification of Resolution

TRICARE Prime Demo will decide whether to expedite an appeal within one business day. We will make reasonable efforts to provide prompt verbal notification to the beneficiary of the decision to expedite or not expedite the appeal; the attempt will be made by phone. If the beneficiary is in a facility, the provider or facility will be notified on the same business day of the decision.

Expedited appeals will be resolved and verbal notification will be made within 72 hours of receipt of the appeal or as expeditiously as the medical condition requires unless the resolution time frame is extended. We will send written notification to both the provider and the beneficiary on the same business day of the decision.

Denied Expedited Appeals

If TRICARE Prime Demo decides not to expedite the clinical appeal because the criteria for expedited review are not met, we will transfer the request to a standard appeal time frame beginning the day the expedited request was received. The beneficiary will be given prompt oral notice of the decision to not expedite including the beneficiary’s expedited grievance rights related to the decision not to expedite the request. A letter will also be sent to the beneficiary at the time of the decision, notifying of the decision to not expedite the appeal, and the appeal will be transferred to the standard appeal timeframe of 60 calendar days. The beneficiary will receive a written letter notifying of the change to the standard timeframe.

Extending an Appeal

TRICARE Prime Demo may extend the time frame to resolve any appeal request when the member agrees to extend the appeal time frame to obtain additional information. We may also request an extension of up to 14 calendar days, if the extension is in the beneficiary’s best interest. The plan will make reasonable efforts to provide the beneficiary with prompt oral notification of the delay and applicable grievance rights. We will notify the beneficiary and their authorized representative in writing of the decision to extend the time frame, the reason for the extension, and applicable grievance rights within two calendar days. We will resolve the appeal as expeditiously as the beneficiary’s health condition requires but no later than the date the extension expires.

Provider Fair Hearing Plan

The Provider Fair Hearing Plan is coming soon. Please review this document outlining the provider participation plan.

Updates & Announcements

Please reference any administrative, medical and reimbursement policies that may apply. Also refer to Updates & Announcements for notifications of changes that may impact your appeal.