Medical Management Guide, 2009, Version 3.0 - Tricare

Medical Management GuideVersion 3.0Utilization ManagementPage 45The grievance and appeal processes are applicableto all TRICARE beneficiaries, subject to thelimitations described in the section for uniformedpatients (see Special Considerations for ActiveDuty Service Members, later in this section). Theprovision of or denial of healthcare services forADSMs based on medical readiness requirementsor fitness-for-duty determinations is not subject tothe grievance or appeal process. Complaints may bemade through the appropriate Chain of Commandor to the Inspector General (IG). Fitness-for-dutydeterminations are addressed through the MedicalEvaluation Board (MEB) and Physical EvaluationBoard (PEB) processes (see Section III, CaseManagement, Disability Evaluation System).The grievance process applies for complaints aboutspecific treatment or coverage (benefit) decisionsother than medical necessity. It is therefore essentialfor MTFs to determine whether the patient’s disputeinvolves a grievance or an appeal.provide appropriate and timely healthcare services,access, or quality; or to deliver the proper level ofcare or service. The grievance process allows theopportunity to report in writing any concern orcomplaint regarding healthcare quality or serviceto which the patient believes he/she is entitled(TRICARE Operations Manual, 6010.51-M, Chapter12, Section 9).Examples of grievances include:• Coverage determinations.• Factors related to quality assurance.• Length of the waiting period to obtain anappointment.• MTF determinations of space-availablecare (including availability of services,pharmaceuticals, equipment, or other items).• Undue delays at an office when an appointmenthas been made.• Refusal of a PCM to provide access to servicesor to refer a patient to a specialist.The appeal process applies when healthcareservices are denied by an MTF based on thedetermination that the services are not medicallynecessary. In such cases, the MTF will neitherprovide nor authorize TRICARE payment forservices.GrievancesTRICARE defines a grievance as a written complaintor concern about a non-appealable issue regardingthe perceived failure by any member of thehealthcare delivery team, including TRICAREauthorizedproviders, military providers, regionalcontractors, or subcontractor personnel, toFiling a GrievanceTo initiate the grievance process, the patient orpatient’s representative submits his/her grievance inwriting through the Customer Service department,the patient advocate, or a similar mechanismdeveloped by the particular MTF for review by theMTF Commander. The Commander (or designee)appoints an “investigator” (most likely the actingChief of Medical Staff) to review the grievance.Within 60 days of the date of the written grievancerequest, the MTF Commander (or designee)forwards a written reply to the patient that includesfindings regarding the grievance.