TennCare Prior Authorization Form: Filing, Timelines, and Appeals

A TennCare prior authorization form is submitted by a provider to the member’s Managed Care Organization (MCO) — or to OptumRx for pharmacy benefits — to get approval before delivering a covered service, drug, or piece of equipment. There is no single universal form. The right one depends on the member’s MCO (BlueCare, UnitedHealthcare Community Plan, Wellpoint, or TennCare Select) and whether the request is for a medication or a medical service. Confirm the member’s current MCO before you download anything, because sending the wrong plan’s form is one of the fastest ways to lose days on the decision clock.

Where to Get the Right Form

Pharmacy Requests

OptumRx handles pharmacy benefits for every TennCare member regardless of MCO. Drug-specific PA forms are posted at OptumRx.com/TennCare, organized by medication and clinical criteria; each asks condition-specific questions, such as whether the patient tried and failed a preferred alternative. For drugs without a dedicated form, use the general TennCare Prior Authorization Required Form (PARF).1TennCare. Pharmacy Benefits Manager2OptumRx. TennCare Prior Authorization Form

Medical Service Requests

For imaging, surgery, durable medical equipment, behavioral health, and other non-pharmacy services, submit to the member’s MCO:

  • BlueCare: forms and portal at bcbst.com.
  • UnitedHealthcare Community Plan: submit through the UnitedHealthcare provider portal or call 866-604-3267.3UHCprovider.com. Prior Authorization and Notification
  • Wellpoint (formerly Amerigroup): Availity Essentials at provider.amerigroup.com/tn, phone 800-454-3730, fax 800-964-3627, behavioral health inpatient fax 877-434-7578.4Amerigroup. Provider Quick Reference Guide
  • TennCare Select: current forms and contacts are posted at tn.gov/tenncare.

Each MCO decides which services require prior authorization beyond what the Bureau of TennCare mandates, and each is required to publish that list to providers.5Tennessee Secretary of State. Tennessee Rules Chapter 1200-13-16 – Medical Necessity One boundary worth knowing: emergency services never require prior authorization, and an MCO cannot deny an emergency claim solely because no preapproval was obtained.6Cornell Law Institute. Tennessee Code 1200-13-13-.04 – Covered Services

What to Have in Front of You Before You Start

Incomplete submissions are the single biggest cause of delayed decisions. Pull the following together before opening the form:

  • The member’s TennCare ID number, printed on the health plan card.7Optum Rx. TennCare Prior Authorization Form
  • The member’s date of birth.
  • The prescriber’s NPI and, for pharmacy forms, DEA number. Medical service forms require at least the NPI.
  • ICD-10 diagnosis codes for the condition being treated.
  • CPT or HCPCS codes for a medical service or piece of equipment.
  • Clinical documentation: recent exam notes, records of prior treatments that failed or were inappropriate, lab results, imaging reports, and any specialist consults that support the request.

The clinical documentation is where most requests are won or lost. A reviewer wants a clean trail: the patient has this diagnosis, these alternatives were tried and didn’t work or aren’t suitable, and the requested service is the appropriate next step. A note that says “patient needs MRI” without explaining why less intensive imaging is insufficient will be flagged.

How to Fill Out the Form

The layout varies by MCO and by pharmacy versus medical, but the sections are consistent.

Member and Prescriber Identification

Enter the member’s full name, TennCare ID, and date of birth. In the prescriber section, enter the ordering provider’s name, NPI, DEA number where applicable, office phone, and fax. The contact information matters — this is how the MCO reaches your office if it needs more records or has issued a decision.

Service or Drug Being Requested

For a pharmacy request, enter drug name, strength, dosage form, quantity, and days’ supply. For a medical service, enter the CPT or HCPCS codes with the quantity or duration. Tie each requested item to its ICD-10 diagnosis code so the reviewer can see the direct link between condition and treatment.

Clinical Criteria

This is the section that carries the most weight. Pharmacy forms ask specific questions — for example, whether the patient tried the preferred formulary alternative and what happened. Medical service forms leave more open space for a clinical summary. Answer every question and fill every text field. A blank checkbox is treated as a missing answer, not a “no,” and will trigger a request for more information that pauses the timeline. If the form has an attachment field, use it; if you’re faxing, send the supporting records right after the form itself.

Prescriber Signature

Most forms require the ordering provider’s signature certifying that the information is accurate and the service is medically necessary. An unsigned form is an incomplete form and will be returned.

How and When to Submit

Route the completed form to the correct payer using its preferred channel:

  • Pharmacy (all MCOs): OptumRx.com/TennCare, or the fax number on the specific drug’s PA form.1TennCare. Pharmacy Benefits Manager
  • Wellpoint medical: Availity Essentials, phone 800-454-3730, fax 800-964-3627, behavioral health inpatient fax 877-434-7578.4Amerigroup. Provider Quick Reference Guide
  • UnitedHealthcare Community Plan medical: UnitedHealthcare provider portal or 866-604-3267.3UHCprovider.com. Prior Authorization and Notification
  • BlueCare medical: BlueCare Tennessee provider portal at bcbst.com.

Tennessee law requires the request to be submitted at least five calendar days before the planned service.8Justia. Tennessee Code 56-7-3705 – Prior Authorization Submissions After submission, the portal or fax confirmation typically returns a tracking or reference number. Save it. That number is the practical way to check status later.

How Long the Decision Takes

Tennessee’s Prior Authorization Fairness Act sets hard deadlines. If the MCO misses them, the request is deemed approved by operation of law.

Standard Requests

The MCO has seven calendar days from submission to approve, deny, or request additional information. If it does nothing in that window, the request is deemed approved.8Justia. Tennessee Code 56-7-3705 – Prior Authorization Submissions If more information is requested, the provider has a reasonable window to respond, and the MCO then has five additional calendar days to decide. The full process cannot exceed seventeen calendar days; if the provider doesn’t supply the requested records within that window, the request expires and must be resubmitted.

Urgent Requests

When a request is flagged urgent, the MCO has seventy-two hours plus one business day to approve, deny, or ask for more information. If it misses that window, the request is deemed approved. If additional information is requested, the provider has seventy-two hours plus one business day to supply it, and the MCO then has the same window to issue a decision.8Justia. Tennessee Code 56-7-3705 – Prior Authorization Submissions

Both the provider and the member receive the decision through the portal or by mail. A denial notice must state the specific reason.

If the Request Is Denied

Internal MCO Appeal

The first step is an appeal to the MCO. Tennessee law requires the appeal to be reviewed by a licensed physician or healthcare professional in the same or a similar specialty as the requesting provider. That reviewer cannot be the person who issued the denial, must consider all submitted records and literature, and cannot be paid based on how many denials are upheld.9Justia. Tennessee Code 56-7-3704 – Appeals of an Electronic and Non-Electronic Prior Authorization Adverse Determination Non-urgent appeals must be decided within seven calendar days, urgent appeals within seventy-two hours plus one business day.

TennCare Medical Appeal

If the MCO upholds the denial, the member (or a provider with the member’s written permission) can file a TennCare Medical Appeal. The deadline is sixty days from the date you learn of the problem.10TennCare. How to File a Medical Appeal To file:

  1. Print the TennCare Medical Appeal form from the TennCare website.
  2. Complete it and keep a copy.
  3. Send it by mail to TennCare Member Medical Appeals, PO Box 593, Nashville, TN 37202-0593; by email to TMMA.Contact.Center@tn.gov; or by fax to 888-345-5575.

Standard appeals can take up to ninety days. If waiting that long would endanger the member’s life or health, call TennCare at 800-878-3192 to request an expedited appeal, which is typically decided within about a week.10TennCare. How to File a Medical Appeal

Keeping Services During the Appeal

If the member was already receiving the service being denied, reduced, or terminated, they can request that services continue while the appeal is pending. Continuation is required when the member files a timely appeal and requests it, and the MCO cannot deny that right even if it failed to inform the member of it.11Cornell Law Institute. Tennessee Code 1200-13-14-.11 – Appeal of Adverse Actions Continuation doesn’t apply when a denial is based on the member exceeding a benefit limit, when a brand-new prescription drug is denied (unless it was previously authorized on an ongoing basis and then made subject to new PA requirements), or when the service falls in a category TennCare does not cover. In an emergency involving a denied prescription drug, pharmacists must provide a single seventy-two-hour interim supply without authorization, so long as that supply stays within pharmacy benefit limits.

What’s Changing in 2026

Under the CMS Interoperability and Prior Authorization final rule (CMS-0057-F), state Medicaid programs and their managed care plans face new transparency obligations in 2026. Impacted payers must publicly post aggregated 2025 PA metrics — approval rates, denial rates, appeal overturn rates, and average processing times — on their websites by March 31, 2026. The federal decision timeframes in the rule (seventy-two hours for expedited, seven calendar days for standard) align with Tennessee’s existing state law.12Centers for Medicare & Medicaid Services. Prior Authorization API The full electronic prior authorization API requirement, which will let providers submit and track requests through standardized digital connections instead of fax or phone, takes effect January 1, 2027.13Centers for Medicare & Medicaid Services. CMS Interoperability and Prior Authorization Final Rule CMS-0057-F Until then, most submissions still move through MCO web portals, phone, or fax.