Medical Review Appeal Process
If your patient’s life or health is in severe danger, you can request an Expedited Appeal by calling us Monday through Friday, 8 a.m. to 6 p.m. (ET).
- BlueCare – 1-888-423-0131
- TennCareSelect – 1-800-711-4104
- CHOICES/ECF CHOICES – 1-888-747-8955
*Any care or service already provided is not considered for an expedited appeal.
Physician-to-Physician Discussion by Phone
If you disagree with a medical review, but you have questions or would like more information, you can speak with a physician about your patient, patient’s condition and care options.
If you disagree with a medical review, the first step in the appeals process is filing a Reconsideration request.
If you receive a denial for Reconsideration or an Expedited Appeal, you can submit a Standard Appeal within 60 days.
Division of TennCare Appeal
If your patient received a denial for services, your office can file an appeal for your patient to the Division of TennCare. The written request must be submitted within 60 days of the denial by mail or fax to:
TennCare Solutions Medical Appeals
P.O. Box 593
Nashville, TN 37202-0593
Medical Review Guidelines
BlueCare Tennessee reviews requests based on medical necessity and the guidelines used for reviews are applied in the following order:
- Division of TennCare
- Centers for Medicare & Medicaid Services
- BlueCross BlueShield of Tennessee Medical Policy
- MCG (formerly Milliman Care Guidelines® ) guidelines adopted by BlueCross BlueShield of Tennessee/BlueCare Tennessee
For complete information, please see the Medical Review Requirements and Criteria section of the Provider Administration Manual.