In the realm of healthcare administration, the Medicaid Reclamation Definition form plays a pivotal role in ensuring the proper management and reimbursement of funds within the Medicaid system, specifically in the State of Tennessee. Crafted by the Bureau of TennCare, this form provides a methodical avenue for healthcare providers to request refunds for services rendered that were erroneously billed to and compensated by the State of Tennessee Bureau of TennCare. Essential to this process is the structured procedure that requires providers to furnish detailed information including, but not limited to, provider information, patient/member details, and third-party liability (TPL) or primary insurance information, which aids in the meticulous examination and expedited handling of each refund request. Furthermore, the form mandates the attachment of a copy of the TennCare Managed Care Organization (MCO) recoupment Explanation of Benefits (EOB) as proof of the recoupment action, underscoring the system's dedication to transparency and accuracy. As providers navigate through refund scenarios—such as having payments recouped by an MCO for a claim already processed and paid by TPL to TennCare—this form stands as an essential document, ensuring that those providing care are justly reimbursed, thereby fostering a fair and efficient healthcare system. With a clear directive and considerate approach towards providers’ grievances, the Medicaid Reclamation Definition form underscores the State of Tennessee’s commitment to the smooth operation of Medicaid services.
| Question | Answer |
|---|---|
| Form Name | Medicaid Reclamation Definition Form |
| Form Length | 2 pages |
| Fillable? | Yes |
| Fillable fields | 61 |
| Avg. time to fill out | 12 min 42 sec |
| Other names | what is a medicaid reclamation claim, what does tpl stand for in medicaid, medicaid reclamation process, medicaid reclamation claim timely filing |
MEDICAID RECLAMATION
CLAIM PROVIDER
REFUND REQUEST FORM
STATE OF TENNESSEE
BUREAU OF TENNCARE
SEND THIS COMPLETED FORM TO:
State of Tennessee
Bureau of TennCare, Floor 4 East
Attention: Fiscal Budget
310 Great Circle Road
Nashville, TN
or
Fax #
Form to be completed by a Provider for services rendered that were billed by and paid to the State of TN Bureau of TennCare: If the Provider has money recouped by an MCO for TPL, and upon billing the TPL (Primary Insurance) was told claim has already been processed and payment (check) sent to State of TN, Bureau of TennCare, P.O. Box 305133, Nashville, TN, 37203.
Provider Information:
Provider Name ______________________________________________________________________________
Street Address _______________________________________________________________________________
City _____________________________________________ State ________________ Zip ________________
Billing Address ______________________________________________________________________________
City _____________________________________________ State ________________ Zip ________________
Contact Name ______________________________________ Contact Phone (_____)______________________
Contact Fax # (_____)__________________ Contact Email ___________________________________________
TN Medicaid Provider Number __________________________ NPI ___________________________________
Tax Identification Number _____________________________________________________________
Member Information:
Patient/Member Name ________________________________________________________________________
TennCare MCO Name __________________________ Member ID# ___________________________________
SSN _________________________________ DOB ____/____/________ Date of Service ____/____/________
Charges $_____________ Amount Recouped $_______________ Date Recouped by MCO ____/____/________
TPL/Primary Insurance Information: (Provide as much information as possible to expedite processing)
TPL (Primary Insurance) Name ____________________________ Member ID# __________________________
Amount paid to TennCare $__________________ Check # ________________ Check Date ____/____/________
Total Check Amount $_______________________ Date Check Cleared ____/____/________
{Attach copy of check if able to obtain from the TPL Carrier}
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Refund Information:
Dollar Amount Due Provider to be refunded by State of TN Bureau of TennCare $_________________________
Brief Description of Situation: __________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Where to Mail Refund:
Mail to Attention of: __________________________________________________________________________
Mail to Address: _____________________________________________________________________________
City: _________________________________________ State: ________________ Zip: ___________________
Provider Attestation:
I hereby certify that the information provided above is correct and that Provider is due amount indicated.
Signature _____________________________________________________ Date ______/______/____________
**NOTE: COPY OF TENNCARE MCO RECOUPMENT EOB MUST BE ATTACHED TO THIS FORM**
[Refund request may take up to 45 days to be completed]
TennCare Internal Use Only Below
Date Request Completed: ________/________/_____________ |
Initials of Fiscal Agent: ________________ |
Revision Date 5/11/2011 |
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