Appealing a Tricare CO-97 Denial
A Tricare CO-97 denial (bundled / already adjudicated) is one of the most common claim rejections behavioral health therapists face. This guide explains exactly what caused the denial and the most effective appeal strategy for behavioral health practices.
What this denial means
The payer says this service is included in another service that's already been billed and paid. In behavioral health, this most commonly happens when an E/M visit (99213/99214) and psychotherapy (90834/90837) are billed on the same day without the -25 modifier on the E/M code to establish that it is a separately identifiable service.
Your appeal strategy
Cite documentation establishing the services as separately identifiable — distinct CPT codes, a separate clinical purpose for each, and (when applicable) the -25 modifier on the E/M code. Reference CMS NCCI Edit Policy Chapter 11, which explicitly permits same-day E/M + psychotherapy when -25 is applied. If the modifier was present and the denial is still issued, request the specific NCCI edit being invoked.
What Tricare requires
P.O. Box 7933
Madison, WI 53707
60 calendar days (Level-1 appeal)
90 days from Level-1 denial
Tricare is a federal program (10 U.S.C. § 1071 et seq.); state insurance law does not apply. Tricare administers its own mental-health and SUD benefit rules under 32 CFR Part 199 and its own appeal process — do not rely on the commercial MHPAEA framework (29 CFR § 2590.712). Verify the current benefit rule and appeal deadline with the regional contractor (Humana Military East / TriWest West) before filing.
Generate your Tricare CO-97 appeal letter
Therapists get 5 free letters every month. Appealing your own denial? It's $19 per letter, one-time, no subscription. No credit card needed to start.
Generate my appeal letter →Frequently asked questions
How long does Tricare have to respond to a CO-97 appeal?
Under federal regulations, Tricare must respond to a Level-1 internal appeal within 60 calendar days. State insurance law, including your state's prompt-payment statute, does not apply to this federal program — confirm the current response-window rules directly with the program administrator before filing. If you receive an adverse determination, you typically have 90 calendar days from the date of the Level-1 denial to request external review. Send the appeal via certified mail or through the payer's portal and keep documentation of the submission date.
Does MHPAEA apply to CO-97 denials?
No. Tricare is not subject to the federal Mental Health Parity and Addiction Equity Act (MHPAEA) at all, so a parity argument does not apply to a CO-97 denial — or any denial — from this payer. Base your appeal on Tricare's own coverage rules and appeal process. Tricare is a federal program (10 U.S.C. § 1071 et seq.); state insurance law does not apply. Tricare administers its own mental-health and SUD benefit rules under 32 CFR Part 199 and its own appeal process — do not rely on the commercial MHPAEA framework (29 CFR § 2590.712). Verify the current benefit rule and appeal deadline with the regional contractor (Humana Military East / TriWest West) before filing.
Can I appeal a CO-97 denial more than once?
Yes. Most payers, including Tricare, allow at least two levels of internal appeal (Level-1 and Level-2 or "expedited" review). Keep copies of every appeal, submission confirmation, and payer response. After exhausting the regional contractor's internal reconsideration, TRICARE appeals escalate to the Defense Health Agency under 32 CFR 199.10. Your state insurance commissioner has no authority over TRICARE — it is a federal program administered by the Department of Defense.
What documentation do I need to appeal a CO-97 denial from Tricare?
At minimum: the original Explanation of Benefits (EOB) or Remittance Advice (RA) showing the CO-97 denial, the original claim details (CPT code, date of service, NPI, charge amount), and any clinical documentation supporting medical necessity. Submit everything in one packet with a cover letter citing the specific denial code, the date of service, and the claim number.