The BCBS Tennessee Provider Reconsideration Form is a one-page PDF that out-of-network providers without a Tennessee practicing location use to request a secondary review of a claim payment or denial. You complete the form, attach documentation that supports your dispute, and fax the package to (423) 535-1959.1BlueCross BlueShield of Tennessee. Provider Reconsideration Form Only one reconsideration is allowed per claim for the same or similar issue, so the first submission needs to be complete.
Who Should Use This Form
The paper form is limited to out-of-network providers without a Tennessee practicing location. In-network providers and those with a Tennessee practicing location submit reconsiderations electronically through the Availity portal instead. Sending the paper form when you should be on Availity can delay or reject your request.1BlueCross BlueShield of Tennessee. Provider Reconsideration Form
The form is for disputing a payment amount or a claim denial you believe was processed incorrectly. Typical reasons include incorrect patient information at processing, duplicate denials when only one claim was submitted, eligibility issues, and billing code disputes. Do not use it for medical necessity denials or claims denied for missing prior authorization. Those go on the separate Provider Appeal Form, and submitting the wrong form burns your one reconsideration opportunity.2BlueCross BlueShield of Tennessee. Provider Appeal Form
What to Gather Before You Start
Pull the following together first. The form asks for each of them, and having the source documents at hand makes the narrative section easier to write.
- Member ID number including the prefix, exactly as it appears on the insurance card
- Your NPI number tied to the claim
- The claim or reference number BCBST assigned when it first processed the claim, from the Explanation of Benefits or Electronic Remittance Advice
- The date of service you are disputing
- The member’s plan type: BlueAdvantage (PPO), BlueCare/TennCare Select, Commercial, BlueCard, CHOICES, CoverKids, or BlueCare Plus (HMO D-SNP)1BlueCross BlueShield of Tennessee. Provider Reconsideration Form
- Supporting documentation: medical records, office notes, corrected claim data, or proof of timely filing
Keep the original EOB or ERA within reach. You will need the specific denial or adjustment reason codes when you write the explanation.
Filling Out the Form
The layout is straightforward. Start at the top with the member section: enter the Member ID Number with prefix, the member’s name, and the date of your request. Then complete the provider section with your name, NPI, the contact person who is handling the dispute, a phone number, and the fax number where BCBST should send the response.1BlueCross BlueShield of Tennessee. Provider Reconsideration Form
Enter the date of service and the claim or reference number for the transaction in dispute. Select the plan type. If you are unsure which plan applies, check the member’s card or the original remittance advice, because the wrong selection slows processing.
The “Reason for Reconsideration” field is where the request is won or lost. Be specific. Reference the denial reason code from your remittance advice, state what was incorrect, and point to the attached documentation that backs your position. “Please review” tells the reviewer nothing. Something like “Claim denied as duplicate — original claim number [X] was voided and this is the corrected resubmission; see attached void confirmation” gives the reviewer a clear path.
Admission-Related Claims
For claims tied to a hospital admission, only the ordering or attending physician or the facility itself can request reconsideration.1BlueCross BlueShield of Tennessee. Provider Reconsideration Form A consulting specialist or ancillary provider on the same admission has to coordinate with the attending’s office or the facility’s billing department.
What to Attach
Attachments depend on the reason for the original denial. Eligibility errors, coding mistakes, and timely filing disputes call for corrected claim data, proof of timely submission, or eligibility verification records. For a coding denial, include the corrected codes and a short explanation of why the original code was wrong. For a timely filing denial, include the original submission confirmation showing the claim was sent within the filing window.
How to Submit
Fax the completed form and every page of supporting documentation to (423) 535-1959.1BlueCross BlueShield of Tennessee. Provider Reconsideration Form Print the fax confirmation and keep it. It is your proof of submission and the record of when BCBST received the request. If you are sending a large packet of records, compare the confirmation page count against what you actually sent to catch any pages that did not transmit.
Response Timelines
For claims under TennCare or HMO plans, Tennessee law requires a response within 30 calendar days, extending to 60 days if BCBST determines it needs more time.3Justia. Tennessee Code 56-32-126 – Prompt Payment Requirements For commercial plans, BCBST’s response window runs between 15 and 60 days depending on the plan’s rules.4BlueCross BlueShield of Tennessee. More Details About My Claims If a delay would keep a patient from urgent care, you can request expedited processing, and BCBST must respond within 72 hours.
A successful reconsideration produces a revised EOB or ERA reflecting the adjustment. If the original decision is upheld, BCBST sends a written determination explaining why.
If the Reconsideration Is Denied
A denial is not the end. File a formal appeal on the BCBST Provider Appeal Form within 60 days of receiving the reconsideration response. The appeal goes to the same fax number, (423) 535-1959, with all supporting documentation.2BlueCross BlueShield of Tennessee. Provider Appeal Form
For TennCare and HMO claims, once the reconsideration process is exhausted you can request an independent review from the Commissioner of Commerce and Insurance. You have 365 calendar days from the date the claim was first denied or payment was recouped to file that written request. The independent reviewer must issue a decision within 60 days, and a ruling in your favor requires BCBST to send full payment within 20 calendar days.3Justia. Tennessee Code 56-32-126 – Prompt Payment Requirements
For fully insured commercial plans, the Tennessee Department of Commerce and Insurance can help at 1-800-432-4029. For self-funded employer plans, the U.S. Department of Labor’s Employee Benefits Security Administration handles oversight at 1-866-444-3272.4BlueCross BlueShield of Tennessee. More Details About My Claims Which regulator applies depends on the type of plan the member carries.