This process was established by statute (Tennessee Code Annotated § 56-32-126(b)(2)) to resolve claims disputes when a provider believes a TennCare managed care company ("MCC") has partially or totally denied claims incorrectly. A MCC's failure to send a provider a remittance advice or other written or electronic notice either partially or totally denying a claim within sixty (60) days of the MCC's receipt of the claim is considered a claims denial.
The independent review statute specifically applies to MCCs licensed as health maintenance organizations or prepaid limited health service organizations (e.g. the behavioral health organizations). TennCare has contractually required its dental benefits manager to also be subject to the independent review process.
The TennCare Oversight Division administers the independent review process, but does not perform the independent review of the disputed claims. When a request for independent review is received, the TennCare Oversight Division determines that the disputed claims are eligible for independent review based on the statutory requirements (i.e. the disputed claims were submitted for independent review within 365 days from the date the MCC's first denied the claims). If the claims are eligible, the TennCare Oversight Division forwards the claims to a reviewer that is not a state employee or contractor and is independent of the MCC and the provider. The decision of the independent reviewer is binding unless either party to the dispute appeals the decision to any court having jurisdiction to review the independent reviewer's decision.
There is a $450 fee associated with an independent review request. If the independent reviewer decides in favor of the provider, the MCC is responsible for paying the fee. Conversely, if the independent reviewer finds in favor of the MCC, the provider is responsible for paying the fee.
The independent review process is only one option a provider has to resolve claims payment disputes with a TennCare MCC. In lieu of requesting independent review, a provider may pursue any available legal or contractual remedy to resolve the dispute.
To learn more about the independent review process, click here for the Information Packet for Independent Review.
To request independent review of disputed claims, click here for the Form to Request Independent Review.
To review the Quarterly Summary of Independent Review Requests, click here.
To Review the Annual Report for Independent Review Pursuant to the TennCare Prompt Pay Act, Tenn. Code Ann. 53-23-126(b)(5), Click Here.