The following information is intended to assist pharmacies with the MAC appeal process.
Appeals must be submitted as required by applicable state law. Appeals exceeding the allowable submission period may be denied. Please refer to the Pharmacy Manual for additional information.
Please submit all MAC Appeal requests using the approved WellDyne MAC appeal spreadsheet provided below:
The WellDyne initial appeal process is available for all prescription drugs or devices in Tennessee for which a pharmacy alleges it did not receive its actual cost.
Providers must file appeals within seven (7) business days of its submission of the initial claim.
WellDyne will investigate and resolve the appeal within seven (7) business days after receipt of the completed WellDyne Adjudication and MAC Appeal Spreadsheet.
The timeline for final determination of the initial appeal will begin once WellDyne has received all of the required information including: 1) a complete version of the WellDyne Adjudication and MAC Appeal Spreadsheet; and 2) certification from the Provider that it has provided all invoices or other records demonstrating the Provider’s actual costs for the drug or medical product or device at issue, including all discounts, price concessions, rebates or other reductions received as of the date that the Provider filed its appeal. If a Provider’s appeal does not contain all information required under TN Rule 0780-01095-.05(2), WellDyne will accept the incomplete appeal and hold it open pending receipt of additional information from Provider. Within five (5) business days of receipt of an incomplete appeal, WellDyne will notify Provider of the information needed to complete WellDyne’s review the appeal. If the Provider provides the requested information, within five (5) business days of receipt of WellDyne’s notice outlining the requested information, WellDyne’s timeline to make final determination shall begin. If the Provider fails to provide the requested information within five (5) business days of receipt of WellDyne’s notice, WellDyne will deny Provider’s appeal. If WellDyne fails to comply with the timing and notice requirements under applicable law, the appeal shall be resolved in favor of the Provider.
Tennessee providers are required to include pharmacy acquisition cost with their appeal submission as outlined below. If a Provider is using the WellDyne Adjudication and MAC Appeal Spreadsheet to submit an appeal, please complete the template and enter acquisition cost information. If the required provider acquisition cost information is not submitted at time of appeal, WellDyne will be unable to review and resolve the appeal and will request resubmission of the appeal with the required information for reprocessing, as more fully described above.
Tennessee providers are required to include the name of the wholesaler or manufacturer, as applicable, from which the pharmacy purchased the drug or medical product or device at issue. A copy of the Provider’s invoice demonstrating the pharmacy actual cost as of the date of the filing can be emailed to RetailManager@netcardsystems.com.