TennCare uses this one-page certificate when a treating clinician wants a member's medical service appeal decided on the expedited track. A typical appeal takes up to 90 days; an expedited one must be decided within one week, or up to three weeks if the health plan gets more time for records. The clinician certifies that the acute presentation is severe enough that waiting could seriously jeopardize the member.
The treating clinician reads the certification statement and, if they agree, signs and dates it, names the desired service and identifies the patient by name and Social Security number or date of birth. The patient may already have requested the expedited appeal from TennCare; the certificate supports that request.
Download the current version from the source each time; forms change without notice.
Provider's Expedited Appeal Certificate
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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According to the certificate, an expedited appeal must be decided within one week, or up to three weeks if the health plan is given additional time to obtain and review medical records. A typical medical service appeal is decided in up to 90 days.
No. TennCare's forms page states that the certificate does not pertain to appeals for TennCare eligibility. It is for appeals about a medical service, where the treating provider certifies that the standard timeframe could seriously jeopardize the patient's health or ability to regain function.
A copy of the office letterhead so TennCare has the provider's contact information. At the provider's discretion, a narrative or medical records supporting the request can also be attached. Everything is faxed together to the Division of TennCare, as soon as possible if the patient has already asked for the appeal.