TRICARE West - Health Net Federal Services Appeals Form

View our authorization appeals and claim appeals pages to find out about the appeal process.

IMPORTANT: Due to the upcoming TRICARE contract change, please note the following submission deadlines.

HNFS can accept authorization appeals through Dec. 31, 2024.
HNFS can accept claim appeals (if the date of service on the claim is before Jan. 1, 2025) through April 30, 2025.

Examples of appealable issues:

authorization or claim denied as not a covered benefit
authorization or claim denied as not medically necessary
Point of Service charges are only appealable when due to an emergency.
payment reduction for no authorization is only appealable when due to an emergency

Examples of non-appealable issues:

charges denied as duplicate, included in allowed amount, incidental or mutually exclusive
charges denied for insufficient information or requested information not received
allowed amount disputes
Point of Service disputes (except when due to an emergency)
authorization or referral redirected to a network provider or military treatment facility

Non-appealable claims issues should be directed to:

TRICARE Claims Correspondence
PO Box 202100
Florence, SC 29502-2100
Fax: 1-844-869-2812

To dispute non-appealable authorization or referral issues, please contact customer service at 1-844-866-WEST (844-866-9378).

Choose Appeal Type

= Required Field

Please choose the appeal type:

Submitter Information

Please complete as many fields as possible

Relationship to Patient / Beneficiary

Describe your relationship

A spouse is not an appropriate appealing party. However, the patient/beneficiary may complete and submit the Appointment of Representative form to appoint you as their representative.

You may appeal on behalf of a dependent child under age 18. A parent of an adult dependent is not an appropriate appealing party unless legal documents such as Power of Attorney are on file with Health Net. However, the patient/beneficiary may complete and submit the Appointment of Representative form to appoint you as their representative.

If legal guardian documents are not on file with Health Net, your appeal will not be accepted. However, the patient/beneficiary may complete the Appointment of Representative form to appoint you as their representative. You may submit other legal documents via fax to 1-888-225-3545.

If you are not listed as the rendering provider on the denied authorization or claim you are not an appropriate appealing party. However, the patient/beneficiary may complete and submit the Appointment of Representative form to appoint you as their representative.

To be an appointed representative, the Appointment of Representative form must be completed and submitted by the patient/beneficiary.

If services have not been rendered and you are a network provider, you are not an appropriate appealing party. However, the patient/beneficiary may complete and submit the Appointment of Representative form to appoint you as their representative.

A PCM is only an appropriate appealing party if you are the rendering provider/facility on the denied authorization or claim. However, the patient/beneficiary may complete and submit the Appointment of Representative form to appoint you as their representative.

A billing service is not an appropriate appealing party. However, the rendering provider/facility may complete and submit the Appointment of Representative form to appoint you as their representative.

You may not be an appropriate appealing party. However, the patient/beneficiary may complete and submit the Appointment of Representative form to appoint you as their representative.

Group/Facility Name

Individual Provider Name

Tax ID Number (TIN)

Agency Name

First Name

Middle Name

Last Name

Date of Birth

Street Address

City

State

Zip Code

Daytime Phone#

Extension

Daytime Fax number

Email Address

As of Jan. 1, 2025, we can no longer accept authorization appeals. Please contact TriWest Healthcare Alliance for any issues regarding referrals or pre-authorizations. Visit www.tricare.mil/west for TriWest's contact information.

As of May 1, 2025, we can no longer accept claims appeals. Please contact TriWest Healthcare Alliance for any issues regarding referrals or pre-authorizations. Visit www.tricare.mil/west for TriWest's contact information.