Tennessee Appeals Information

Tennessee providers may use Prodigy’s appeals process for MAC and non-MAC related reimbursement appeals. Providers are encouraged, but not required to submit appeals using the Prodigy electronic submission system. However, providers may use either Prodigy’s standard appeals form or the State of Tennessee appeals form.

1. Prodigy Standard Appeals Forms available for electronic submission here. Forms are also available for submission by e-mail, fax or regular mail: (A) Authorization and (B) MAC Appeals

2. Tennesse Standard Appeal Form - Consistent with TN state law, Prodigy has certified to the State that it will accept this standard appeal form created by the Tennesse Department of Health to file an initial appeal. If a provider chooses to use the Tennessee Standard Pharmacy Reimbursement Appeal Form, the completed forms can be emailed to providers@prodigyrx.com. with the email subject “TN Appeal.”

There is no cost to providers for filing an initial appeal and providers are not required pay any fees for submission of an appeal.

Tennessee providers are required to include the name of wholesaler or manufacturer, as applicable, from which the pharmacy purchased the drug or medical product or device, as well as the acquisition cost of the drug product or the device under appeal. If the required information is not submitted at time of appeal, Prodigy will be unable to review and resolve the appeal and will request resubmission of the appeal with the required information for reprocessing. Providers may e-mail a copy of the pharmacy’s invoice demonstrating the pharmacies actual cost to providers@prodigyrx.com.

Pharmacies or Pharmacy Services Administration Organizations (PSAO’s) and Group Purchasing Organizations (GPO’s) in the Prodigy Pharmacy Network may submit a reimbursement appeal within sixty (60) days or within such time period as may be required by applicable state law, following the initial claim submission.

Appeals may be submitted, using the Prodigy Standard Form through electronic submission (available for submission by e-mail, fax or regular mail: (A) Authorization and (B) MAC Appeals). Providers may also submit an appeal using the Tennesse Standard Appeal Form, pursuant to State law, to providers@prodigyrx.com or via fax or mail.

Pharmacies, PSAOs and GPOs will first receive an acknowledgement of receipt of the appeal within twenty-four (24) hours, and an official response to the appeal within three (3) business days following the receipt of the appeals.

Each appeal received is entered into a database and tracked electronically through every step of the appeals process, from entry to resolution. Prodigy’s provider relations team manages the appeals process and are trained to communicate with the provider in a timely manner to keep them appraised throughout the appeals process. Providers can check on the status of each appeal by e-mailing providers@prodigyrx.com or calling the Provider Relations phone number.

If the initial appeal is granted, the Pharmacy will receive an official letter from Prodigy specifically outlining each drug product or national drug code in the appeal that was approved. Furthermore, Prodigy will take additional steps to ensure that past and future payments for are adjusted accordingly to reflect the appeal.

If the appeal is denied:

Pharmacy will receive an official letter from Prodigy specifically outlining each drug product or national drug code in the appeal, stating the reason for denial and with a specified licensed wholesaler(s) where the drug product may be purchased by the pharmacy at a price matching or below the reimbursement.

If the appeal is granted:

Pharmacy will receive an official letter from Prodigy specifically outlining each drug product or national drug code in the appeal that was approved. Furthermore, Prodigy will take steps to ensure that past and future payments are adjusted accordingly.

An appeal maybe submitted for any drug product or device eligible for coverage under the formulary or the applicable benefit plan of the patient with the specific claim.