Tennessee Medical Billing and Payer Rules

Timely Filing in Tennessee

Tennessee and the Federal No Surprises Act

This page cites no Tennessee surprise billing statute for state-regulated plans. The federal Act supplements state laws and applies wherever a state law does not.

Major Payers

How Does TennCare Work for Billing?

Tennessee runs Medicaid as TennCare, administered by the Division of TennCare inside the Tennessee Department of Finance and Administration. The state's own quarterly monitoring report to CMS names the Division of TennCare as the agency behind the TennCare III demonstration (Project No. 11-W-00369) and describes the program as a single, statewide managed care service delivery system.

For a billing team the practical meaning is simple. Most TennCare claims do not go to one state claims system. They go to a managed care organization (MCO), and each MCO has its own portal, provider manual and claim edits. Learn the plan before you learn the program. The general rules are in our Medicaid billing guide.

Which Plans Does TennCare List?

TennCare's managed care organizations page lists the same four health plans in West, Middle and East Tennessee: Wellpoint (formerly Amerigroup), BlueCare, UnitedHealthcare Community Plan and TennCare Select. Each region's list also names the counties it covers. The CMS-hosted TennCare III monitoring report for January to March 2024 shows the same four plan names, plus DentaQuest and Optum columns for the dental and pharmacy contractors.

Plan names and contracts change, so confirm the current list with the Division of TennCare before you load a payer table.

What the Claim Path Looks Like

1. Verify eligibility and the member's assigned plan for the date of service. The plan, not the Division, adjudicates the claim.
2. Submit the claim to that plan in the format its manual requires. Hospital claims are institutional (UB-04 data sent as an 837I), physician claims are professional (CMS-1500 data sent as an 837P).
3. Read the remittance and the denial reasons. Correct and resubmit when the denial is a data problem, and appeal only when the plan decision itself is wrong.
4. Start the plan's appeal clock on the day the denial is issued.

What Is the TennCare Timely Filing Limit?

TennCare managed care organization (MCO) claims must be filed within 120 calendar days. TennCare's policy PAY 13-001 (Rev. 2, June 1, 2022) sets that limit for MCOs and for the dental benefits manager, one year for the pharmacy benefits manager, and one year for claims TennCare pays itself on a fee-for-service basis, such as ICF/IID, certain waiver and Department of Children's Services claims, and Medicare crossovers.

Timely filing is normally counted from the date of service. If a member's eligibility was made retroactive, the clock for an MCO starts on the date TennCare notifies the MCO of the enrollment, and for TennCare itself on the date the record is loaded. School-based therapy and audiology claims under an IEP have a one year limit with an MCO. If a Medicare claim did not cross over automatically and is past one year, the provider has six months from the Medicare payment or denial notice to ask TennCare for crossover payment directly. Federal rule 42 CFR 447.45(d)(1) sets the 12 month ceiling under all of this.

How the Medicare Clock Can Move

Under 42 CFR 424.44(b), the one-year limit is extended in four situations: an administrative error by a Medicare contractor or agent, retroactive Medicare entitlement, retroactive entitlement where a state Medicaid agency recovered its payment six months or more after the service, and retroactive disenrollment from a Medicare Advantage plan after the plan recovered its payment. In each case the extension runs through the last day of the sixth calendar month after the triggering event. An administrative error request made more than four years after the date of service is not eligible.

Under 42 CFR 424.44(c), a deadline that falls on a weekend or federal holiday moves to the next workday.

Who Is the Medicare Contractor for Tennessee?

Palmetto GBA, LLC is the Medicare Administrative Contractor (MAC) for Tennessee. CMS states that JJ processes fee-for-service Medicare Part A and Part B claims for Alabama, Georgia and Tennessee. One contractor therefore handles Part A hospital claims and Part B professional claims for the whole state, so your rejection and denial handling stays consistent across both.

The home health, hospice and DME rows come from the CMS MACs-by-state list dated March 2023, the newest version we found. Recheck it before you route those claims.

Medicare Timely Filing and Appeals

Medicare fee-for-service claims must be filed within one calendar year of the date of service under 42 CFR 424.44(a)(1). If Palmetto GBA denies a claim and the denial is wrong, the first appeal is a redetermination. Under 42 CFR 405.942, a request must be filed within 120 calendar days from the date the party receives the notice. Receipt is presumed to be 5 calendar days after the date of the notice unless evidence shows otherwise, and the contractor may extend the window if you show good cause.

The next level is reconsideration by a qualified independent contractor. Under 42 CFR 405.962 that request must be filed within 180 calendar days from the date the party receives the redetermination notice, with the same 5-day presumption of receipt.

For payer-level detail on Medicare billing, see Medicare billing rules.

Does Tennessee Have a Prompt Pay Law, and What Does Federal Medicaid Timing Require?

Tennessee regulates how fast commercial insurers must pay in Tenn. Code Ann. 56-7-109. A 2014 Department of Commerce and Insurance bulletin says the section requires clean claims to be paid no later than 30 calendar days after the insurer receives the claim, and defines a clean claim as one with no defect, impropriety or missing required documentation. An earlier Department citation, from 2003, described the section as giving 30 calendar days for paper claims and 21 days for electronic claims, with three allowed responses: pay the claim, pay the undisputed part and explain the rest in writing, or explain in writing why it is not clean. We have not confirmed the current statute text or the late-payment interest rate, so check the code before you cite a figure in a dispute letter.

The Medicaid side has a federal rule we did open. Under 42 CFR 447.45(d), a Medicaid agency must pay 90 percent of clean claims from practitioners within 30 days of receipt and 99 percent within 90 days. A clean claim there is one that can be processed without obtaining additional information from the provider, and the date of receipt is the date the agency receives the claim, as shown by its date stamp.

Managed care is covered by 42 CFR 447.46. A contract with an MCO must provide that the organization will meet the same requirements. The MCO and its providers may, by mutual agreement, set an alternative payment schedule, and any alternative schedule must be stipulated in the contract.

Does Tennessee Have Its Own Surprise Billing Law?

This page cites no Tennessee surprise billing statute for state-regulated plans, and we state none. The CMS Questions and Answers on the No Surprises Act and State Laws, revised August 2023, lays out how the layers fit: the federal No Surprises Act supplements state surprise billing laws and does not replace them. If a state has a law that does not apply to a specific item or service, the federal Act applies to it.

When a state law does apply, the CMS document says the state law generally controls as long as it gives protections equal to or stronger than the federal Act. A "specified state law" is one that provides a method for determining the total amount payable to an out-of-network provider or facility, and where one applies it sets the out-of-network rate and the amount behind patient cost sharing.

• States have primary enforcement authority over insurers, facilities and providers, and CMS enforces any provision a state fails to substantially enforce.
• A state cannot enforce its surprise billing protections against a self-funded plan unless the plan has opted into the state law.
• The No Surprises Help Desk, 1-800-985-3059, can tell a caller whether federal or state law applies and which state agency to contact.

The practical consequence for a Tennessee emergency group or hospital: until you confirm a state pathway in writing from the Tennessee Department of Commerce and Insurance, run out-of-network disputes through the federal route. That means open negotiation and then federal IDR for items and services the Act covers. Our overview of state surprise billing laws explains how to check each state.

Balance Billing for Ground Ambulances

The federal Act covers air ambulance services. This page cites no official source that settles ground ambulance balance billing for Tennessee state-regulated plans, so it states no rule for it. Ask the plan and the Department of Commerce and Insurance in writing before you bill a patient above the plan's allowed amount.

Which Payers Matter in Tennessee?

Name only the payers you can show are in your state. For Tennessee Medicaid the official roster is the TennCare managed care organizations page: Wellpoint, BlueCare, UnitedHealthcare Community Plan and TennCare Select. For Medicare the contractor is Palmetto GBA. For commercial and Medicare Advantage business, this page cites no Tennessee Department of Commerce and Insurance market share report, so this page lists no commercial payers and gives no market share figures.

Plan type decides which law applies. A fully insured plan is regulated by the state, a self-funded plan is governed by ERISA.

How Do You Appeal a Denial from a TennCare Plan?

Start with the denial notice and the plan's provider manual. TennCare claims are decided by the MCO, so the first appeal normally goes to the plan, using the form and address the plan names. This page does not state the TennCare appeal deadlines, so the steps below are the method, not the dates.

1. Pull the remittance and match every denial reason to a CARC and RARC. A denial for missing data is a correction, not an appeal.
2. Check the date on the denial notice and the plan's written deadline. Record both in your tracker the same day.
3. Assemble the claim, the notice, the medical record pages that answer the denial reason and any authorization number.
4. Send the appeal by the route the plan's manual names, and keep proof of the date it reached the plan.

Our denial management team works denials within 48 hours of posting, which leaves most of the appeal window for building the case.

How We Handle Billing in Tennessee

For Tennessee clients we separate the claim paths first: TennCare plans, Palmetto GBA Medicare, and commercial payers. Each path gets its own filing clock, held to the shortest written deadline in the plan manual or contract. Claims go out within 24 hours of charge entry, and denials are worked within 48 hours.

For out-of-network emergency and facility claims we run eligibility checks first, because the plan type decides whether a state process could apply, then open negotiation and federal IDR where the Act covers the service. Hospitals and facilities can see how we run UB-04 claims, and the out-of-network billing and IDR service covers the dispute work end to end.

To review your Tennessee payer mix and filing clocks, book a call.