"Request to Commissioner for Independent Review of Disputed Tenncare Claim" - Tennessee

Request to Commissioner for Independent Review of Disputed Tenncare Claim is a legal document that was released by the Tennessee Department of Commerce and Insurance - a government authority operating within Tennessee.

Form Details:

  • Released on January 7, 2016;
  • The latest edition currently provided by the Tennessee Department of Commerce and Insurance;
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  • Fill out the form in our online filing application.

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TennCare Oversight Division
Phone: (615) 741-2677
th
500 James Robertson Parkway, 11
Floor
Fax: (615) 401-6834
Nashville, TN 37243
TennCare.Oversight@TN.gov
Request to Commissioner for Independent Review of Disputed TennCare Claim
Please complete this form fax or mail it back to us. You will be copied on our correspondence concerning this matter.
Please provide documentation that supports your complaint.
DO NOT send any Member Protected Health Information (PHI) via email unless you have HIPAA compliant encrypted
email. PHI includes the members name and other demographic information.
Complainant Information
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Provider Representative
* Required field
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Prefix:
Mr.
Mrs.
Ms.
Dr.
First Name*:
Last Name*:
Street Address:
City:
State:
Zip Code:
Phone Number:
Daytime / Alternate:
Fax Number:
Email Address:
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Provider Name & NPI#
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Prefix:
Mr.
Mrs.
Ms.
Dr.
LLC
PC
INC
Name*:
NPI #*:
Street Address:
City:
State:
Zip Code:
Phone Number:
Daytime / Alternate:
Fax Number:
Email Address:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
1
IR Request Form 010716
Page 1 of 4
TennCare Oversight Division
Phone: (615) 741-2677
th
500 James Robertson Parkway, 11
Floor
Fax: (615) 401-6834
Nashville, TN 37243
TennCare.Oversight@TN.gov
Request to Commissioner for Independent Review of Disputed TennCare Claim
Please complete this form fax or mail it back to us. You will be copied on our correspondence concerning this matter.
Please provide documentation that supports your complaint.
DO NOT send any Member Protected Health Information (PHI) via email unless you have HIPAA compliant encrypted
email. PHI includes the members name and other demographic information.
Complainant Information
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Provider Representative
* Required field
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Prefix:
Mr.
Mrs.
Ms.
Dr.
First Name*:
Last Name*:
Street Address:
City:
State:
Zip Code:
Phone Number:
Daytime / Alternate:
Fax Number:
Email Address:
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Provider Name & NPI#
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Prefix:
Mr.
Mrs.
Ms.
Dr.
LLC
PC
INC
Name*:
NPI #*:
Street Address:
City:
State:
Zip Code:
Phone Number:
Daytime / Alternate:
Fax Number:
Email Address:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
1
IR Request Form 010716
Page 1 of 4
TennCare Oversight Division
Phone: (615) 741-2677
th
500 James Robertson Parkway, 11
Floor
Fax: (615) 401-6834
Nashville, TN 37243
TennCare.Oversight@TN.gov
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
TennCare Plan Information
Amerigroup RealSolutions (Amerigroup of TN HMO)
UnitedHealthcare Community Plan (UnitedHealth Care of the River Valley HMO)
BlueCare (Volunteer State Health Plan HMO)
My Complaint is against:
TennCare Select (Volunteer State Health Plan HMO)
DentaQuest (Dental Benefit Manager)
Magellan (Pharmacy Benefit Manager)
Physical Health
Behavioral Health
Dental
Type of Service:
Pharmacy
CHOICES
Transportation
Provider Type:
Provider Type examples: Hospital, Physician, Nursing Facility, Hospice, etc.
Date(s) of Service(s):
Start Date:
End Date:
Initial Claim Submission to MCC Date:
(Attach a copy of the Provider Claim.)
Initial MCC Claim Denial or Recoupment Date:
(Attach a copy of the MCC Denial or Recoupment Advice.)
Date Provider submitted written Reconsideration Request to MCC:
(Attach a copy of the Provider’s Reconsideration Request)
Date Provider received written Reconsideration Denial:
(Attach a copy of the MCC’s Reconsideration Denial)
Are you a contracted network provider?
Yes
No
(If Yes, attach evidence of contract. A copy of the signature page is sufficient.)
If you are not contracted with the MCC, you must submit the reviewer’s fee with this request.
Have you enclosed the Fee?
Yes
No
Per claim, attach a check in the amount of $750 made payable to the Department of Commerce and Insurance.
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IR Request Form 010716
Page 2 of 4
TennCare Oversight Division
Phone: (615) 741-2677
th
500 James Robertson Parkway, 11
Floor
Fax: (615) 401-6834
Nashville, TN 37243
TennCare.Oversight@TN.gov
Reason(s) for Complaint
Claim Denial = [CD]
[CD] Untimely Filing
[CD] Neither Paid nor Denied
Claim Paid Incorrectly
[CD] Service Not Covered
[CD] Enrollee Not Eligible on DOS
[CD] Hosp In-Patient vs Observation
[CD] Lack of Authorization
[CD] Experimental/Investigational
[CD] Other
Claim Recoupment Error
[CD] Medical Necessity – General
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
ALL
Only claims which meet
of the requirements set forth in T.C.A. § 56-32-126(b) (2) (A) thru (D) are eligible for
Independent Review. Claims payment disputes involved in litigation, arbitration or not associated with a TennCare
member are not eligible.
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Please give a written description of the problem:
(Attach additional pages if needed)
Description may include, but not limited to: reason given for denial and your position explaining why the MCO should
pay the claim. Include all pertinent information
Attach copies of pertinent documentation, including any correspondence from the plan and remittance advices.
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
________________________________________ _______________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
3
IR Request Form 010716
Page 3 of 4
TennCare Oversight Division
Phone: (615) 741-2677
th
500 James Robertson Parkway, 11
Floor
Fax: (615) 401-6834
Nashville, TN 37243
TennCare.Oversight@TN.gov
_______________________________________________________________________________________________________________________
Do you want your claims aggregated?
Yes
No
Only claims involving a common question of fact or law may be aggregated. The fact that a claim is not paid does not
create a common question of fact or law.
If you wish to aggregate your claims, explain the common question of fact or law:
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
ACKNOWLEDGEMENT OF FEE OBLIGATION
By my signature below, I hereby request independent review of the above claim, pursuant to T.C.A. §§ 56-32-126(b) or 71-5-2314. I also confirm
that the above mentioned disputed claim will not be raised as an issue in litigation or arbitration until the reviewer issues his decision. Any
provider who brings a lawsuit or initiates arbitration involving a claims payment dispute raised in an independent review request before the
independent reviewer renders a decision, must ultimately pay the independent reviewer’s fee. Any provider who initiates independent review for
a non-TennCare claim is ultimately responsible for paying the reviewer’s fee. I also understand that there is a mandatory fee of $750.00 per claim
and if I have a contract with the MCO, the MCO is initially responsible for paying the fee. I further understand that if the reviewer determines the
MCO correctly denied payment of this disputed claim(s), then I must reimburse the MCO for the reviewer’s fee as established by the Selection
Panel for TennCare Reviewer’s.
If you are NOT the aggrieved provider, what is your relationship to the provider?
_________________________________
I declare that the information I’ve furnished is true and accurate.
Signature:
Date:
___________________________________________________
_______________________________________________
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IR Request Form 010716
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