Appeals and Claims with CHAMPUS Health Insurance Plans
Part 2, Chapter 8: CHAMPUS and Medical Savings Accounts Page 4
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The CHAMPUS programs reportedly work reasonably well for most routine claims. However, as with any program, there are times when errors, misunderstandings, or disagreements may occur. If you're having difficulty obtaining reimbursement or medical services that you think are appropriate under the CHAMPUS system, there is an established appeals procedure.
The first step is to file a claim appeal with the company that originally processed the claim. If services were provided through the traditional CHAMPUS program, the claim appeal should be filed with the local plan administrator. If services were provided through the newer program, the claim appeal should be filed with the local Tri-Care center. If those claim appeals are unsuccessful, you can file a claim appeal directly with the national Tri-Care Support office (See Appendix B).
When filing a claim appeal, it's essential to include copies of all EOBS (Explanation of Benefits Statements) and medical bills, as well as a brief explanation of the problem. While the appeals are being processed, it's important to continue to keep detailed records of all medical bills, even when the claims are filed by the providers. If you have specific questions about CHAMPUS rules, you can call the national Tri-Care Support office for further information (See Appendix B).
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