Ventegra ACI Appeal Process

All appeal requests requiring pricing review must be submitted within 30 days of the claim date unless otherwise specified by state regulations below. NOTE: Please see below for state-specific requirements.

All requests MUST include purchasing invoice along with the ACI Appeal Form. Claims without a purchasing invoice will not be reviewed.

Please fax the completed form and purchasing invoice to (858) 551-8175.

If you have any questions, please contact Pharmacy Network at network@ventegra.com or 877-867-0973.

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State-specific Requirements

Indiana Appeal Process:
Pharmacy has the right to appeal a claim not to exceed sixty (60) days following the initial filing of the claim.

Tennessee Initial Appeal Process:

1. Pharmacy must submit completed ACI Appeal Form with its initial appeal.
2. Pharmacy must file its initial appeal within seven business days of its submission of the initial claim for reimbursement for the drug or medical product or device.
3. Pharmacy shall provide the PBM with a copy of the invoice(s) demonstrating the pharmacy's actual cost as of the date of the filing of the initial appeal and the name and contact information of the wholesaler or manufacturer from which it purchased the prescription drug or device.
4. In the event the pharmacy does not provide complete information in its initial appeal, Ventegra shall so notify the pharmacy of such deficiency within five days of its receipt of the incomplete information. The pharmacy shall then have five business days from the date of Ventegra's notice of the deficiency to provide the additional information. In the event the pharmacy does not provide the additional information in full within that five days, Ventegra may deny the initial appeal pursuant to T.C.A. § 56-7-3260(c)(4).
5. PBM will make a final determination resolving the pharmacy's initial appeal within seven business days of receipt of an initial appeal that includes all required information.
6. 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.
7. Pharmacy will not be assessed any costs for any services provided in connection with the initial appeal.
8. Ventegra's ACI Appeal Form can be used or pharmacy may use the Tennessee Standard Pharmacy Reimbursement Appeal Form.
9. In the event Ventegra fails to comply with the aforementioned timing and notice requirements as required under T.C.A. § 56-7- 3206(c)(2)(B)(ii), 0780-01-95-.03 (2)(h), and 0780-01-95-.05 (5), the pharmacy's initial appeal shall be resolved by Ventegra in favor of the pharmacy.