Tennessee Medical Payment Committee Review Request Form

• Category: Tennessee Workers Compensation - Official
• State: Tennessee
• Control #: TN-SKU-1582
• Format: PDF

Description

Medical Payment Committee Review Request Form The Tennessee Medical Payment Committee Review Request Form is a document used by healthcare providers in Tennessee to request a review of a disputed medical service or item from the Tennessee Medical Payment Committee (TPC). This form includes sections for the provider to provide information about the patient, the medical service/item, and any supporting documents. There are two types of Tennessee Medical Payment Committee Review Request Forms: a Physician/Supplier Request Form and a Hospital Request Form. The Physician/Supplier Request Form is for individual providers or suppliers requesting a review from the TPC, while the Hospital Request Form is for hospitals or their affiliates requesting a review from the TPC. Both forms must be filled out completely to be considered for review.

The Tennessee Medical Payment Committee Review Request Form is a document used by healthcare providers in Tennessee to request a review of a disputed medical service or item from the Tennessee Medical Payment Committee (TPC). This form includes sections for the provider to provide information about the patient, the medical service/item, and any supporting documents. There are two types of Tennessee Medical Payment Committee Review Request Forms: a Physician/Supplier Request Form and a Hospital Request Form. The Physician/Supplier Request Form is for individual providers or suppliers requesting a review from the TPC, while the Hospital Request Form is for hospitals or their affiliates requesting a review from the TPC. Both forms must be filled out completely to be considered for review.