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Tennessee Reimbursement Appeals
Appeal Process,
Appeal Forms, and Appeal Submission
This Reimbursement Appeals Process is available for all prescription drugs or
devices in Tennessee for which a pharmacy alleges it did not receive actual cost
Step 1) Appeal Process - How To File An Appeal
For information on our Appeal Process
click here.
Step 2) Appeal Forms
To begin the Appeal Process, download and complete the following forms
-
Appeal Form
-
Appeal Certification
Step 3) Submit an Appeal
To submit an Appeal, upload the fully completed Appeal Forms from Step #2, provide contact information below, and click “submit” at the bottom of this webpage.
Appeal Form
*
Limited to PDF.
Appeal Certification
*
Limited to PDF
Please provide the following information, which will be used to transmit an email confirming
receipt of the Appeal Forms, with the date/time of receipt
Pharmacy or Chain Contact Name
First
Last
Please provide us with the key contact's name.
Pharmacy or Chain Contact Email
*
Unique ID
Please direct any additional questions or concern to the following:
Email:
providerrelations@gateway-networks.com
Gateway Pharmacy FAX number:
937.755.1431
Citizen’s Rx Pharmacy Help Desk:
888.316.6510
Citizen’s Rx FAX number:
888.557.0896
