If you are a healthcare provider, it is important to understand the concept of Medicaid reclamation. In plain terms, this term refers to the process of reclaiming payments that were made under the Medicare or other public assistance programs for costs incurred by providing health care services (including those medically necessary) paid from Medicaid funds. To ensure these payments are processed efficiently and properly, providers must become familiar with the forms and processes related to Medicaid reclamation and how they affect their own reimbursements. This blog post will explain what is required in order to file a Medicaid Reclamation Definition Form and what information is needed on it.
| Question | Answer |
|---|---|
| Form Name | Medicaid Reclamation Definition Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | medicaid reclamation claim definition, what is a medicaid reclaimation claim, medicaid reclamation process, medicaid reclamation act |
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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