Form IN-2003 "Request for Independent Review of Disputed Tenncare Program Episode of Care Cycle Provider Gain/Risk Share Total" - Tennessee

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What Is Form IN-2003?

This is a legal form that was released by the Tennessee Department of Commerce and Insurance - a government authority operating within Tennessee. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2020;
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Download Form IN-2003 "Request for Independent Review of Disputed Tenncare Program Episode of Care Cycle Provider Gain/Risk Share Total" - Tennessee

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TennCare Oversight Division
Phone: (615) 741-2677
500 James Robertson Parkway
Fax: (615) 401-6834
Nashville, TN 37243
TennCare.Oversight@TN.gov
Request for Independent Review of Disputed TennCare Program Episode of Care Cycle
Provider Gain/Risk Share Total
Please complete and submit by email to
TennCare.Oversight@tn.gov
(preferred), fax, email, or mail. We will acknowledge
receipt of your Request by email. You will be copied on our correspondence concerning this matter by email. Please
provide documentation that supports your dispute.
DO NOT send any Member Protected Health Information (PHI) via email unless you have HIPAA compliant encrypted
email. PHI includes the member’s name and other demographic information.
Requesting Provider 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 and National Provider Identifier (NPI)
____________________________________________________________________________________________________
Prefix:
Mr.
Mrs.
Ms.
Dr.
First Name*: ____________________________________
NPI#*: _________________________________________
Street Address: _____________________________________________________________________________________
City: ____________________________________
State: ___________
Zip Code: __________________
Phone Number: ___________________________
Daytime / Alternate: ___________________________________
Fax Number: _____________________________
Email Address: _________________________________________
1
IN-2003 (Rev.9/2020)
RDA 11278
TennCare Oversight Division
Phone: (615) 741-2677
500 James Robertson Parkway
Fax: (615) 401-6834
Nashville, TN 37243
TennCare.Oversight@TN.gov
Request for Independent Review of Disputed TennCare Program Episode of Care Cycle
Provider Gain/Risk Share Total
Please complete and submit by email to
TennCare.Oversight@tn.gov
(preferred), fax, email, or mail. We will acknowledge
receipt of your Request by email. You will be copied on our correspondence concerning this matter by email. Please
provide documentation that supports your dispute.
DO NOT send any Member Protected Health Information (PHI) via email unless you have HIPAA compliant encrypted
email. PHI includes the member’s name and other demographic information.
Requesting Provider 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 and National Provider Identifier (NPI)
____________________________________________________________________________________________________
Prefix:
Mr.
Mrs.
Ms.
Dr.
First Name*: ____________________________________
NPI#*: _________________________________________
Street Address: _____________________________________________________________________________________
City: ____________________________________
State: ___________
Zip Code: __________________
Phone Number: ___________________________
Daytime / Alternate: ___________________________________
Fax Number: _____________________________
Email Address: _________________________________________
1
IN-2003 (Rev.9/2020)
RDA 11278
TennCare Oversight Division
Phone: (615) 741-2677
500 James Robertson Parkway
Fax: (615) 401-6834
Nashville, TN 37243
TennCare.Oversight@TN.gov
Health Plan Information
Amerigroup (Amerigroup of TN HMO)
United Healthcare Community Plan (UnitedHealthcare of the River Valley
My Complaint is against Managed Care
HMO)
Company/Managed Care Organization
BlueCare (Volunteer State Health Plan HMO)
(“MCC/MCO”):
TennCare Select (Volunteer State Health Plan HMO)
Select One
Episode from Dropdown
Type of Episode:
Provider Type: _________________________________
Provider Type examples: Hospital, Physician, or Physician Group
Date(s) of Episode of Care Cycle Performance Report Period:
Start Date: __________________________
End Date: ________________________
Episode of Care Performance Report Date: ________________________
(Attach a copy of the Final Episode of Care Provider Performance Report)
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)
2
IN-2003 (Rev.9/2020)
RDA 11278
TennCare Oversight Division
Phone: (615) 741-2677
500 James Robertson Parkway
Fax: (615) 401-6834
Nashville, TN 37243
TennCare.Oversight@TN.gov
Reason(s) for Dispute Not Reaching the Correct Total Gain/Risk Share:
Average Cost calculated incorrectly
All valid episode service claims not included
Included claims that were not valid episode service claims
Risk Sharing Factor was calculated incorrectly
Report did not include the total number of cycle valid episodes (included and excluded)
Risk adjustment methodology not based on the reports of risk markers and risk weight on the MCO’s web site.
Episode Gain Sharing Limit incorrect
Quality Metrics Acceptable Thresholds used not correct
Quality Metrics Commendable Threshold used not correct
Other
ALL
Only Episodes of Care Provider Performance Reports which meet
of the requirements set forth in T.C.A. § 56-32-
126(b)(2)(A)-(D) are eligible for Independent Review. Disputes involved in litigation, arbitration, or those 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 is not limited to, your position explaining why the value of the MCO’s Total Gain/Risk Share is
incorrect. Please include all pertinent information in your position description.
Attach copies of pertinent documentation, including correspondence to and from the MCO, Episode of Care Quarterly
Preview Reports, or remittance advices (as applicable) concerning this Episode of Care.
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
3
IN-2003 (Rev.9/2020)
RDA 11278
TennCare Oversight Division
Phone: (615) 741-2677
500 James Robertson Parkway
Fax: (615) 401-6834
Nashville, TN 37243
TennCare.Oversight@TN.gov
Written description of the problem (continued):
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
ACKNOWLEDGEMENT OF FEE OBLIGATION
By my signature below, I hereby request Independent Review of the above Episode of Care, pursuant to T.C.A. § 56-32-126(b). I also confirm that the
above-mentioned disputed Episode of Care Provider Performance Report 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 an Episode of Care dispute raised in an Independent Review
request before the Independent Reviewer renders a decision must ultimately pay the Independent Reviewer’s fee. I also understand that there is a
mandatory fee of $750.00 per claim and the MCO is initially responsible for paying the fee. l further understand that if the Reviewer determines
the calculation of the Episode of Care Cycle Total Gain/Risk Share is correct, then I must reimburse the MCO for the Reviewer’s fee as established
by the Selection Panel for TennCare Reviewers.
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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IN-2003 (Rev.9/2020)
RDA 11278
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