Form IN-2000 "Provider Complaint: Tenncare and Coverkids Programs" - Tennessee

What Is Form IN-2000?

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;
  • The latest edition provided by the Tennessee Department of Commerce and Insurance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form IN-2000 by clicking the link below or browse more documents and templates provided by the Tennessee Department of Commerce and Insurance.

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Download Form IN-2000 "Provider Complaint: Tenncare and Coverkids Programs" - 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
PROVIDER COMPLAINT: TennCare and CoverKids Programs
Please complete and submit by email (preferred), fax, or mail. We will acknowledge receipt of your Complaint by email.
You will be copied on our correspondence concerning this matter by email. 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 and NPI#
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Prefix:
Mr.
Mrs.
Ms.
Dr.
Name*: _____________________________________ NPI#*: _________________________________________
Street Address: ________________________________________________________________________________
City: _____________________________________
State: __________
Zip Code: ___________________
Phone Number: ________________________
Daytime / Alternate: _____________________________
Fax Number: _________________________
Email Address: _________________________________________
1
FORM IN2000 (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
PROVIDER COMPLAINT: TennCare and CoverKids Programs
Please complete and submit by email (preferred), fax, or mail. We will acknowledge receipt of your Complaint by email.
You will be copied on our correspondence concerning this matter by email. 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 and NPI#
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Prefix:
Mr.
Mrs.
Ms.
Dr.
Name*: _____________________________________ NPI#*: _________________________________________
Street Address: ________________________________________________________________________________
City: _____________________________________
State: __________
Zip Code: ___________________
Phone Number: ________________________
Daytime / Alternate: _____________________________
Fax Number: _________________________
Email Address: _________________________________________
1
FORM IN2000 (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
TennCare Plan Information
Amerigroup (Amerigroup of TN HMO)
UnitedHealthcare Community Plan (UnitedHealth Care of the River Valley HMO)
BlueCare (Volunteer State Health Plan HMO)
TennCare Select (Volunteer State Health Plan HMO)
My Complaint is against:
DentaQuest (Dental Benefit Manager)
Optum Rx (Pharmacy Benefit Manager)
Division of TennCare (Bureau) (Medicare Cross-Over Claims) TennCare
Division of TennCare (Bureau) (Medicaid Reclamation Claims)
Physical Health
Behavioral Health
Dental
Type of Service:
Pharmacy
CHOICES
Transportation
Provider Type: ______________________________________
Provider Type examples: Hospital, Physician, Nursing Facility, Hospice, etc.
Enrollee Name: _______________________________________________
DOB: _________________
If there are multiple enrollees, the names and DOBs do not need to be listed here. Include them in the supporting
documentation/description of the problem.
Date(s) of Service(s):
Start Date: ______________________
End Date: ______________________
Reason(s) for Complaint
Claim Denial = [CD]
[CD] Untimely Filing
[CD] Enrollee Not Eligible on DOS
[CD] Service Not Covered
[CD] Lack of Authorization
[CD] Experimental/Investigational
[CD] Other
Claim Payment Delay
Claim Paid Incorrectly
Duplicate
Recoupment Error
Medical Necessity – General
Credentialing problems
Non-renewal of Provider Agreement and/or Network Status
Other MCC operational problems
Medical Necessity – Hospital Inpatient vs Hospital Observation
2
FORM IN2000 (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
Please give a written description of the problem:
(Attach additional pages if needed)
Include all pertinent information.
Attach copies of pertinent documentation, including any correspondence from the plan and remittance advices.
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
If you are complaining about claim denials/recoupments for services rendered to 5 or more health plan members, please
submit an Excel Spreadsheet that includes the following information:
Member Name (First, Middle, Last)
Service Type
Member Birth Date (DOB)
Service Location/Facility Name
From Service Date (FDOS)
Remit Date (Denied or Paid)
To Service Date (TDOS)
Issue &/or other information that would assist in resolving this complaint
Do NOT include multiple MCCs in one spreadsheet
Tell us what you want the TennCare MCC or the TDFA Division of TennCare (Bureau) to do to resolve your complaint.
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
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: _____________________
3
FORM IN2000 (Rev. 9/2020)
RDA 11278
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