Medical billing services in Tennessee

TennCare is run by the Division of TennCare, Tennessee Department of Finance and Administration. Provider enrollment goes through the TennCare Provider Registration Portal¹, at pdms.tenncare.tn.gov, and fee-for-service claims go through the member's TennCare MCO (listed by region)², at www.tn.gov. Managed care statewide: three managed care organizations, BlueCare, UnitedHealthcare Community Plan and Wellpoint (formerly Amerigroup), serve TennCare members in each of the West, Middle and East Tennessee regions, and TennCare Select is listed in every region as well². TennCare reports that all three MCOs have passed NCQA accreditation. The member's health plan is printed on the TennCare card.

TennCare managed care timely filing (every MCO, under the TennCare contract): 120 calendar days from the date of service to file a claim with the member's MCO, with the clock starting later for third-party liability, retroactive enrollment and school-based services³. With a third party involved, the clock starts when the third party resolves the claim; with retroactive enrollment, when the MCO is notified of the enrollment; and school districts billing IEP, IHP or IFSP services get 365 days. After a notice that a claim is invalid or incomplete, the provider has at least 60 days from the notice or 120 days from the date of service, whichever is later, to send a valid claim, and corrections to a paid claim go in as adjustments within 120 days of the payment notice.

Managed care plans²

• BlueCare
• UnitedHealthcare Community Plan
• WellpointFormerly Amerigroup
• TennCare SelectAssigned plan for QMB-only members

Each plan is credentialed separately, has its own portal and its own appeal route. A practice that joins Tennessee Medicaid through one plan is not in network with the others until each contract is in place.

Commercial payers active in Tennessee⁶: BlueCross BlueShield of Tennessee, UnitedHealthcare Insurance Company, Cigna Health and Life Insurance Company, Celtic Insurance Company, Oscar Insurance Company, Alliant Health Plans, UnitedHealthcare Ins Co of River Valley. A Tennessee practice works to a separate provider manual for each, with its own filing window, corrected-claim process and appeal levels. Verified payer deadlines, each with its source, are in the timely filing limits table.

For Medicaid managed care, the clean-claim payment standard under Tenn. Code Ann. 56-32-126(b)(1): 90 percent of clean claims processed, and paid if appropriate, within 30 calendar days of receipt, and 99.5 percent of all claims within 60 calendar days⁴. The TennCare Oversight Division of the Department of Commerce and Insurance measures each MCO against this standard. Clean CHOICES and ECF CHOICES claims submitted electronically are held to a faster contract standard: 90 percent within 14 days and 99.5 percent within 21 days. Commercial insurers answer instead to Tenn. Code Ann. 56-7-109, the state's prompt-pay statute for health insurance entities. In A/R follow-up, a managed care claim that is past that standard is raised with the plan, with the contract term cited.