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TennCare TC0140 Abortion Medical Necessity Form

TennCare needs this one-page certification with the claim for an abortion provided to a member. Based on professional judgment, the physician who performed the abortion certifies one of two reasons printed on the form: credible evidence that the pregnancy resulted from rape or incest, or a physical condition that would place the woman in danger of death unless an abortion is performed. Supporting documents are attached.

Who completes it

The physician performing the abortion completes it: date of service, the individual's name, date of birth and address, the reason, the supporting documentation, and the physician's NPI and address. The physician must sign and date it in their own handwriting after the procedure.

Submitting and payment

How to submit it
Send the signed certification and its attachments to the member's TennCare managed care organization with the claim. If a claim is denied because of a problem with the form, the form may be corrected and resubmitted to the MCO.
Who pays
The certification supports payment of the abortion claim by the member's TennCare MCO, and a claim denied over a form error can be paid once the corrected form is resubmitted.

Good to know

  • Check only one reason. For rape or incest, attach documentation from law enforcement, or from a public health agency, the Department of Human Services or a counseling agency such as a rape crisis center.
  • For the life-endangerment reason, attach medical records documenting the lifesaving nature of the abortion; an Other line lets the physician specify additional documentation.
  • Correction fluid is not allowed. Per TennCare's ASH forms FAQ, strike through the original text with a line, write the correction nearby, and initial and date it.
  • Fields other than the signature can be typed or handwritten, and the form may be reproduced locally. It is Form TC0140 (Rev. April 24, 2015), with instructions revised June 21, 2022.

Get the official form

Download the current version from the source each time; forms change without notice.

Certification of Medical Necessity for Abortion

Official pagePDFVersión en español

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Frequently asked questions

Who signs the TennCare Certification of Medical Necessity for Abortion?

The physician who performed the abortion. TennCare's instructions say the physician must sign and date the form at the same time, in their own handwriting, after the procedure. The physician's NPI and complete address also go on the form, and the date of service is the date the abortion was performed.

Is the TennCare abortion certification available in Spanish?

Yes. TennCare's Miscellaneous Provider Forms page posts the Certification of Medical Necessity for Abortion in English and Spanish, alongside instructions for completing it, the Hysterectomy Acknowledgment Form in both languages, and the sterilization consent form with its instructions.

Can a TennCare abortion certification be corrected after a claim denial?

Yes. TennCare's ASH forms FAQ says a form that caused a claim denial may be corrected and resubmitted to the MCO for payment. Correction fluid is not permitted: strike through the original text with a line, write the corrected text nearby, and initial and date the change.