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  1. #1

    Default Tricare and Skilled Nursing Care

    Background: After my Dad exhausted his Medicare coverage for skilled nursing care Tricare became responsible. After months of review claiming "insufficient medical records/information" Tricare has decided to deny claims for my Dad's skilled nursing care with the explanation: "Not Medically Necessary".

    1) Who is responsible for filing an appeal with Tricare? The nursing home or the family?

    2) If the appeal is denied, is the patient responsible for paying for medical services deemed "not medically necessary?"

    Thank you.

  2. #2
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    Default Re: Tricare and Skilled Nursing Care

    Quote Quoting Samson
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    Background: After my Dad exhausted his Medicare coverage for skilled nursing care Tricare became responsible. After months of review claiming "insufficient medical records/information" Tricare has decided to deny claims for my Dad's skilled nursing care with the explanation: "Not Medically Necessary".

    1) Who is responsible for filing an appeal with Tricare? The nursing home or the family?

    2) If the appeal is denied, is the patient responsible for paying for medical services deemed "not medically necessary?"

    Thank you.

    First, call Tricare and ask what medical information was missing and the actual reason the claim was denied. "Not medically necessary" may mean many things. Get the first and last name of the Tricare rep and their title. Then, take that information to the Billing Department of the Nursing Home and ask them to submit an appeal and include the missing information. The Nursing Home may need to include certain records that may have been omitted when the claim was filed, or your Father's condition may not meet Tricare's requirements for skilled nursing.

    If the appeal process is exhausted, and the final determination is "not medically necessary", then yes, the patient is responsible for the bill.

    Good luck.

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