Medical Billing in Tennessee

What is specific to Tennessee

TennCare enrols nearly its whole Medicaid population in managed care organizations, so eligibility, prior authorization and claims run through the member's health plan rather than a state fee-for-service desk.

Tennessee’s Medicaid programme is TennCare. Practices with a meaningful TennCare mix usually need it worked as its own queue rather than mixed into commercial follow-up, because the submission path, the timely filing window and the appeal route are all different.

What a medical billing seat does in Tennessee

Aged accounts receivable called until they close, and denials read, appealed and tracked.

In Tennessee the queue that costs the most is TennCare: 1 year from the date of service, and a claim past that date is unpayable rather than late.

• Worklist worked from the difficult end, not the easy end
• Every call logged with the payer reference and the outcome
• Denials categorised so the same reason stops recurring
• Appeals written and submitted, not just re-bills
• Weekly written summary of what moved and what did not
• Worked during Tennessee business hours, not queued overnight

Most of the Tennessee work we see comes out of Nashville, Memphis and Knoxville, though nothing about a seat depends on where your office is — the queue is worked through your system, not from your building.

Tennessee borders 8 states, and practices near those lines almost always carry at least one out-of-state Medicaid enrollment. That is a separate portal, a separate filing window and a separate appeal route from TennCare, and it is the queue that most often goes unworked because it belongs to nobody.

What Tennessee law gives you

21 calendar days for electronically submitted claims; 30 calendar days for paper claims (Tenn. Code Ann. § 56-7-109) — within that window the health insurance entity must pay a clean claim or tell the provider in writing why it is not clean

Source.

TennCare, in practice

TennCare is delivered almost entirely through at-risk managed care, not fee-for-service, with three MCOs (Wellpoint — formerly Amerigroup, BlueCare, and UnitedHealthcare Community Plan) plus the separate non-risk TennCare Select plan for defined populations; verbatim: "Medical, behavioral and long-term care services are covered by 'at risk' Managed Care Organizations (MCOs) in each region of the state, and each participating MCO creates their own contracts with providers, maintains their own fee schedules, processes their own claims" and "All 3 Managed Care Organizations for TennCare have passed the NCQA (National Committee for Quality Assurance) accreditation process." Source

Tennessee writes a timely-filing rule directly into its prompt-pay statute: a claim filed more than 90 days after the date of service is not a "clean claim" at all, so it loses every prompt-pay protection and interest right. Verbatim: "'Clean claim' does not include any claim submitted more than ninety (90) days after the date of service." Practical effect: a 90-day internal filing deadline on commercial TN claims, far tighter than the 12-month norm elsewhere. Source

On the commercial side the dominant Blue plan here trades as BlueCross BlueShield of Tennessee, Inc. (its TennCare/Medicaid arm trades as BlueCare Tennessee, a separate BCBSA licensee), which matters mainly because its portal and its appeal route are the ones your seat will spend the most time in. Source

How long you have to file a TennCare claim

1 year from the date of service. A resubmission or follow-up of a denied claim within 6 months of the date the original was filed.

“All claims must be filed within one (1) year of the date of service except in the following circumstances:” Tenn. Comp. R. & Regs. 1200-13-13-.08 — Providers

A claim past that date is not late, it is unpayable, and no appeal recovers it. It is the one queue where a week of nobody working it is money that does not come back — which is the argument for working TennCare as its own queue rather than mixing it into commercial follow-up. Every state’s limit is listed here.

Working Tennessee hours

Tennessee runs on Central time, 11 hours behind our floor in Rawalpindi. To be at a desk for your nine to five, the shift here runs 8pm to 4am, and 7pm to 3am once the clocks go forward. Pakistan does not observe daylight saving, so the shift moves on this side rather than yours.

One wrinkle worth naming: the eastern third of the state runs on Eastern time. If your practice sits on that side of the line, say so on the call and the shift is set to your clock rather than the one most of the state keeps.

That is the part that decides whether follow-up happens at all: a payer’s phone lines are open on Tennessee hours and nobody else’s.

What it costs in Tennessee

$1,650

Per seat, per month, in US dollars — $19,800 a year for one full-time person, forty hours a week, on Tennessee hours. No annual contract, no percentage of collections, no setup fee and no software to buy. Seat prices across all roles in Tennessee run $1,450 to $2,450; the full list is published.

That is the entire invoice. Run your own figures against a percentage vendor or a hire rather than take ours.

Getting started in Tennessee

About a week from a signed agreement to a person working your queue, and that week of training on your workflow is not billed on top. The work happens in your own system under a login you issue, so there is nothing to migrate and nothing to install. The week, step by step, and what is signed before anyone has access.

Questions