TRICARE Manuals - Display Chap 12 Addendum A (Change 8, Jun 13, 2024) (2024)

(Reproduce Locally)

SAMPLE FORMAT

I appoint (Print/TypeName and Address of Representative) to act as my representativein connection with my appeal under 32CFR 199.10, Appeal and Hearing Procedures. To avoid thepossibility of a conflict of interest, I understand that an officeror employee of the United States (US), to include an employee ormember of a Uniformed Service, an employee of a Uniformed Servicelegal office, a Market/Military Medical Treatment Facility (MTF)provider or a Beneficiary Counseling and Assistance Coordinator(BCAC), is not eligible to serve as a representative. An exceptionto this is made when an employee of the US or member of a UniformedService is representing an immediate family member.

I authorize the Defense HealthAgency (DHA) to release to said representative, information relatedto my medical treatment, and if necessary, photocopies of any medicalrecords which may be required for adjudication of my claim for TRICAREbenefits.

I understand that the representativeshall have the same authority as the party to the appeal and noticegiven to the representative shall constitute notice to the party.

This consent will expire uponthe issuance of the final agency decision regarding my appeal; however,I reserve the right to withdraw this authorization at any time.

________________________

(Date)

___________________________________________

(Signature of PersonGiving Consent)

Prohibition on redisclosure:

Further disclosure of informationby the appointed representative may only be made in accordance withthe provisions of the Privacy Act of 1974, the Health InsurancePortability and Accountability Act of 1996 (HIPAA), and other applicableFederal law.

preparation of amount in disputedata

a.

Initial determination date

Enter date of the initial determination,which is usually the TRICARE Explanation of Benefits (EOB) date.

b.

ICN(s) of claims appealed

Enter the ICN of each claimbeing appealed.

c.

Billed charges

Enter total amount billed forthis (these) claim(s).

d.

Allowable charges

Enter total allowable amount.For purposes of determining “amount in dispute,” include the amountwhich would have been “allowable” if the service/supply denied wouldhave been payable.

e.

Amount denied

Enter the amount of the “allowablecharges,” which were denied. Do not include any “allowable charge”reductions.

f.

Deductible amount

Enter amount of deductible,if any, applied to this (these) claim(s).

g.

Amount paid by other insurance

Enter amount of other insurancepayment applicable.

h.

Amount paid by TRICARE

Enter amount actually paidby TRICARE on this (these) claim(s).

i.

Amount paid by cost-share

Enter amount actually to bepaid by the beneficiary/sponsor. If other insurance covers the entirecost-share, enter Ø.

TMA FORM 607

REV. JAN. 88

An appeal in your behalf hasbeen received from (Name of Person who requested Appeal).Under 32 CFR 199.10, (Nameof Person), is not an appropriate appealing party, and, consequently,the request cannot be accepted as an appeal.

The TRICARE case file doesnot indicate that you have appointed anyone as representative toact in your behalf. Therefore, if you wish to appeal you have thefollowing options:

a.Appealin your behalf.

b.Appointa representative who may request an appeal in your behalf.

If you intend to appeal inyour own behalf or through a duly-appointed representative, theappeal must be received within 20 calendar days of the date of thisletter or by the appeal deadline set forth in the initial determinationnotice (whichever is later).

An Appointment of Representativeform is enclosed for your convenience should you wish to appointa representative. Your correspondence should be addressed to:

(Contractor’s Name AndAddress)

Signature

cc:

Improper Appealing Party

SAMPLE FORMAT

If you are the TRICARE beneficiary,the non-network participating provider of care, or a provider ofcare, or if you are the appointed representative of one of the above,you may appeal this initial determination. Your request must be inwriting, must be signed, and must be postmarked or received by (insertname of contractor, postal address, email address, and fax number)within 90 calendar days from the date of this decision. If you usethe United States Postal Service (USPS), then the postmark or cancellationmark will be used as the date received. If you use a method otherthan the USPS or if the postmark is not legible, then the date ofreceipt will be the date your request was filed in our office.

Your appeal should includethe following:

When appointing someone torepresent you in the appeals process, be aware that officers andemployees of the United States (US) are not eligible to serve asrepresentation. This exclusion is to prevent a possible conflictof interest and includes: employees or members of the US military,employees or staff members of a Uniformed Service legal office,or Beneficiary Counseling and Assistance Coordinator (BCAC). Thisrestriction is subject to exceptions in Title 18, United StatesCode (USC), Section 205. An exception is usually made for an employeeor member of the US military who represents an immediate familymember.

Upon receiving your request,all TRICARE claims related to the entire course of treatment willbe reviewed.

SAMPLE FORMAT

If you are the TRICARE beneficiary,or the appointed representative of the TRICARE beneficiary, andare dissatisfied with this initial determination, you may requestan expedited reconsideration. Your request must be in writing, mustbe signed, and must be postmarked or received by (insert nameof contractor, postal address, email address, and fax number)within three calendar days from the date of this denial determination.A request for expedited reconsideration received after three calendardays but earlier than 90 calendar days will be treated as a non-expedited,or normal, reconsideration. If you use the United States PostalService (USPS) to submit your request, then the postmark or cancellationmark will be used as the date received. If you use a method otherthan the USPS or if the postmark is not legible, then the date ofreceipt will be the date your request was filed in our office.

Your appeal should includethe following:

When appointing someone torepresent you in the appeals process, be aware that officers andemployees of the United States (US) are not eligible to serve asrepresentation. This exclusion is to prevent a possible conflictof interest and includes: employees or members of the US military,employees or staff members of a Uniformed Service legal office,or Beneficiary Counseling and Assistance Coordinator (BCAC). Thisrestriction is subject to exceptions in Title 18, United StatesCode (USC), Section 205. An exception is usually made for an employeeor member of the US military who represents an immediate familymember.

Upon receiving your request,all TRICARE claims related to the entire course of treatment willbe reviewed.

SAMPLE FORMAT

If you are the TRICARE beneficiarywho is currently an inpatient in the facility, or if you representthe TRICARE beneficiary who is currently an inpatient in the facility,and if you are dissatisfied with the initial determination, you mayrequest reconsideration. Your request must be in writing, must besigned, and must be postmarked or received by (insert nameof contractor, postal address, email address, and fax number).Expedited requests must be submitted by noon of the day followingthe date of receipt of this denial determination. A request receivedafter this deadline but earlier than 90 calendar days from the dateof this denial determination will be accepted and processed as anon-expedited, or normal, request. If you use the United StatesPostal Service (USPS) to submit your request, then the postmarkor cancellation mark will be used as the date received. If you usea method other than the USPS or if the postmark is not legible,then the date of receipt will be the date your request was filedin our office.

Your appeal should includethe following:

When appointing someone torepresent you in the appeals process, be aware that officers andemployees of the United States (US) are not eligible to serve asrepresentation. This exclusion is to prevent a possible conflictof interest and includes: employees or members of the US military,employees or staff members of a Uniformed Service legal office,or Beneficiary Counseling and Assistance Coordinator (BCAC). Thisrestriction is subject to exceptions in Title 18, United StatesCode (USC), Section 205. An exception is usually made for an employeeor member of the US military who represents an immediate familymember.

Upon receiving your request,all TRICARE claims related to the entire course of treatment willbe reviewed.

SAMPLE FORMAT

“If you decide to proceed withthe service or it has already been provided, and the service isprovided by a network provider who was aware of your TRICARE eligibility,you may be held harmless from financial liability despite the servicehaving been determined to be non-covered by TRICARE. A network providercannot bill you for non-covered care unless you are informed inadvance that the care will not be covered by TRICARE and you waiveyour right to be held harmless by agreeing in advance (which agreementis evidenced in writing) to pay for the specific non-covered care.If the service has already been provided when you receive this letterand it was provided by a network provider who was aware of yourTRICARE eligibility, and if there was no such agreement and youhave paid for the care, you may seek a refund for the amount youpaid. This can be done by requesting a refund from (insert contractorname and address).

Include documentation of yourpayment for the care, by writing to the above address. If you havenot paid for the care and have not signed such an agreement, anda network provider is seeking payment for the care, please notify (insertcontractor name and address).

Under hold harmless provisions,the beneficiary has no financial liability and, therefore, has nofurther appeal rights. If, however, you agree(d) in advance to waiveyour right to be held harmless, you will be financially liable and theappeal rights outlined below would apply. Similarly, the appealrights outlined below apply if you have not yet received the careor if you received the care from a non-network provider and thereis $50.00 or more in dispute.”

SAMPLE FORMAT

If you are the TRICARE beneficiary,the non-network participating provider of care, or a provider ofcare who has been denied approval under TRICARE, or the appointmentrepresentative of one of the above, you have the right to requesta (insert level of appeal). Your request must be inwriting, signed, and postmarked or received by (insert contractorname, postal address, email address, and fax number or Appealsand Hearings Division, DHA, 16401 E. Centretech Parkway, Aurora,Colorado 80011-9066), within (insert number of calendaror business) days from the date of this decision. If youuse the United States Postal Service (USPS) to submit your request,then the postmark or cancellation mark will be used as the datereceived. If you use a method other than the USPS or if the postmarkis not legible, then the date of receipt will be the date your requestwas filed.

Your appeal should includethe following:

Upon receiving your request,all TRICARE claims related to the entire course of treatment willbe reviewed.