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Get Medicaid Reclamation Claim Provider Refund Request Form - Tn
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How to fill out the Medicaid Reclamation Claim Provider Refund Request Form - Tn online
Filling out the Medicaid Reclamation Claim Provider Refund Request Form - Tn is an important step for providers seeking refunds for recouped amounts. This guide will provide you with clear, step-by-step instructions to help you complete the form accurately and efficiently online.
Follow the steps to fill out the Medicaid reclamation claim provider refund request form online:
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Fill out the provider information section. Include your provider name, street address, city, state, and zip code. Make sure to provide a billing address, contact name, phone number, fax number, email address, TN Medicaid provider number, NPI, and tax identification number.
- Next, complete the member information section. Include the patient/member name, TennCare MCO name, member ID number, social security number, date of birth, and date of service, along with details regarding the charges, amount recouped, and date recouped by MCO.
- In the TPL/Primary Insurance information section, provide as much information about the primary insurance as possible, including name, member ID, amount paid to TennCare, check number, check date, total check amount, and check clearance date. Attach a copy of the check if possible.
- Fill out the refund information section detailing the dollar amount due to the provider and a brief description of the situation regarding the refund request.
- Specify the mailing details for the refund, including the attention name, address, city, state, and zip code.
- Complete the provider attestation by certifying that the information provided is correct. Sign and date this section.
- Ensure that a copy of the TennCare MCO recoupment Explanation of Benefits (EOB) is attached to the form.
- After reviewing all the provided information for accuracy, you can save changes, download, print, or share the form for submission.
Complete your Medicaid reclamation claim provider refund request form online today!
TennCare is a federal waiver program that is approved by the Centers for Medicare & Medicaid Services (CMS). Under the waiver, TennCare can do some things that Medicaid can't do. TennCare can enroll some people who are not eligible for Medicaid. TennCare can offer more benefits than Medicaid.