(T.C.A. § 56-7-3206(c)(2); CHAPTER 0780-01-95)
Integrated Prescription Management, Inc. (“IPM”) has established a process for contracted providers within the State of Tennessee to file an initial pricing appeal in accordance with Rule 0780-01-95.
A contracted pharmacy or the pharmacy’s designee may file an appeal within seven (7) business days of an initial claim submission for reimbursement, if: a) the price/unit for a particular drug or medical product or device is below the cost at which the drug or medical product or device is generally available for purchase by pharmacies in the state of TN from national or regional wholesalers or b) IPM has placed a drug on the MAC list in violation of 56-7-3106. An appeal may be initiated regardless of whether an appeal was previously submitted. IPM will respond with a final determination within seven (7) business days of receipt of an appeal.
The appealing party can submit an initial appeal form along with supporting documentation using one of the methods below:
1) Secure email to MACappeals@rxipm.com
2) Facsimile (800) 476-2691; or
3) By mail to:
Integrated Prescription Management, Inc.,
7815 N. Palm Ave., Suite 400,
Fresno, CA 93711
For assistance with initiating an appeal by telephone, contact IPM Helpdesk at (877)-860-8846 and select Option 2. Appeals initiated by telephone must be followed up with a complete written or electronic request within five (5) business days.
An Initial Appeal will be considered sufficient if a complete initial appeal form has been received and supporting documentation is provided that demonstrates the pharmacy’s actual cost for the drug or medical product or device. The documentation shall include all discounts, price concessions, rebates, or other reductions received as of the date the pharmacy filed its initial appeal.
By submitting a complete initial appeal with the required documentation, the pharmacy certifies it has provided IPM with all invoices or other records demonstrating the pharmacy’s actual cost for the drug or medical product or device at issue, which will take into account all discounts, price concessions, rebates, or other reductions received as of the date the pharmacy filed its initial appeal.
If IPM determines an initial appeal is incomplete, IPM will notify the pharmacy within five (5) business days of receipt of the incomplete appeal requesting additional information. The pharmacy will have five (5) business days from receipt of the notice to provide the requested information. If the information is not received, IPM may deny the initial appeal. IPM will not delay the review of an initial appeal by requiring more information than is required or for administrative or non-substantive errors or omissions.
IPM will provide written notification via secure email or facsimile of the final determination of an initial pricing appeal within seven (7) business days of receipt of a complete initial appeal. In the event IPM fails to provide notice within seven (7) business days, the appeal shall be resolved in favor of the pharmacy.
For initial appeals resolved in favor of the pharmacy, IPM will adjust the price to the initial date of service within three (3) days of the determination for the appealing pharmacy and all other contracted pharmacies in the network that filled a prescription for patients covered under the same health plan. Other contracted pharmacies in the network that filled a prescription for patients covered under the same health plan will be notified via facsimile.
The appealing pharmacy and all other contracted pharmacies in the network that filled prescriptions for patients covered under the same health benefit plan will have sixty (60) days from the date of notification to resubmit claims and receive retroactive payment based on the adjusted MAC price from the initial date of service the appealed drug was dispensed. Retroactive price adjustments will be made in the next payment cycle.
Pursuant to Rule 0780-01-95 and TC 56-7-3206, a contracted pharmacy may file an external appeal with the DOI following the final determination made by IPM. To learn more about filing an external appeal, please visit the TN DOI External Payment Appeals website.