Provider Complaint Process

• We are the State agency that regulates the TennCare and CoverKids programs’ managed care companies.
  • We are not part of the Tennessee Department of Finance and Administration (TDFA), A Division of TennCare (Bureau).
  • We are located within the Department of Commerce & Insurance (TDCI).
• We assist in the regulatory oversight of Medicare Advantage Special Needs Plans for Medicare/Medicaid Dual Eligibles (MA SNPs and/or D-SNPs) operating in Tennessee.

• The Tennessee HMO law (T.C.A.§ 56-32-101 et seq);
• The Contracts between the Division of TennCare and the Managed Care Companies (MCCs);
• The Medicare Improvement for Patients and Providers Act of 2008 (MIPPA); and
• The Contracts between the Division of TennCare and the Tennessee Medicare Advantage Special Needs Plans (MA SNPs).

• Review and approve/disapprove provider agreement templates, unique provider agreements, and provider manuals for TennCare, CoverKids, and MA SNP MCCs.
• Review and approve TennCare and CoverKids subcontractor agreements and operational relationships.
• Oversee financial solvency of the MCCs.
• Examine, review, and test for TennCare and CoverKids claims payment promptness and accuracy.
• Process Provider Complaints from providers of services delivered to TennCare and CoverKids enrollees to facilitate complaint resolution in an informal setting.
• Process Provider Complaints from providers of services delivered to TennCare/Medicare dual eligible enrollees to facilitate complaint resolution in an informal setting.
• Provide administrative support for the Independent Review Process of provider claims for services delivered to TennCare enrollees. (Effective 1/1/21, also for CoverKids)
• Process enrollee complaints that need to be forwarded to the Division of TennCare or the MCCs for resolution.

• A process available to providers of services delivered to TennCare, CoverKids, or MA/MA SNP enrollees who have a complaint about the Division of TennCare or an MCC.
• This process is free.
• The TennCare Oversight Division requires MCCs to respond to complaints from providers concerning operational and claims disputes in a timely manner.
• The TennCare Oversight Division uses information regarding disputed claims and other MCC operations to monitor, examine, and enforce MCC compliance.

• The Complaint process is faster than Independent Review.
• You can still pursue Independent Review as long as you submit your IR request prior to 365 days from the date of the initial denial or recoupment.
• If the Complaint concerns an older payment dispute, the Provider Complaint process is available even if more than 365 days have passed from the date of the initial denial or recoupment.
• You do not pay a fee if you are unsuccessful. The IR law requires the party who does not prevail to pay a fee.

 TennCare HMO MA SNP Plans:

• Amerigroup/Amerivantage Speciality +
• UnitedHealthcare of the River Valley/UnitedHealthcare Dual Complete
• Volunteer State Health Plan/BlueCare Plus

Non-TennCare HMO MA SNP Plans

• Cigna-HealthSpring TotalCare (HMO SNP)
• Humana Gold Plus
• Windsor/WellCare Comp Access

Complaints may involve, but are not limited to:

• Claims denials;
• Claims payment accuracy;
• Claim processing timeliness;
• Credentialing procedures;
• Inability to obtain assistance from the MCC; or
• Questions about MCC policy and procedures.

• ASH Form
• Coding Disputes
•  Lack of Authorization
• Medical Necessity
• Non-Par Provider
• TPL
• Untimely Filing
• Readmission within 30 days
• Enrollee not eligible on DOS
• Claim paid incorrectly

Complaints about non-TennCare health plans regarding payment disputes for services should be directed to the TDCI Insurance Division Consumer Insurance Services Section at:

Consumer Insurance Services Section – Vickie Trice, Director
500 James Robertson Parkway, 
Nashville, TN 37243-0574
800-342-4029 | (615) 741-2218
Fax: (615) 532-7389

https://www.tn.gov/commerce/insurance/consumer-resources.html

Consumer Insurance Services exists to educate consumers and mediate insurance-related disputes.

Remember, complaints about services payment disputes for services rendered by Medicare dually eligible TennCare members (including complaints about MA and MA SNP plans) should be directed to the TennCare Oversight Division.

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TennCare Oversight has website information about the Provider Complaint Process

• Information about the Provider Complaint process is located at: https://www.tn.gov/commerce/tenncare-oversight/mco-dispute-resolution.html
• This website has Provider Complaint forms to assist providers in submitting a complaint. Use of these forms is not mandatory. There are 3 forms:
  • TennCare/CoverKids Provider Complaint Form
  • MA-SNP Provider Complaint Form
  • TennCare Provider Episode of Care Report Provider Complaint Form1

Episode-based payment seeks to align provider incentives with successfully achieving a patient's desired outcome during an “episode of care,” which is acute or specialist-driven health care delivered during a specified time period to treat a physical or behavioral condition. Ultimately the provider gets a “report”. If a provider disagrees with the report, use the Episode of Care Report Provider Complaint form.

• Information about the Provider Complaint process is located at: https://www.tn.gov/commerce/tenncare-oversight/mco-dispute-resolution.html
• This website has Provider Complaint forms to assist providers in submitting a complaint. Use of these forms is not mandatory. There are 3 forms:
  • TennCare/CoverKids Provider Complaint Form
  • MA-SNP Provider Complaint Form
  • TennCare Provider Episode of Care Report Provider Complaint Form

Episode-based payment seeks to align provider incentives with successfully achieving a patient's desired outcome during an “episode of care,” which is acute or specialist-driven health care delivered during a specified time period to treat a physical or behavioral condition. Ultimately the provider gets a “report”. If a provider disagrees with the report, use the Episode of Care Report Provider Complaint form.

• When a Complaint is received, the TennCare Oversight Division forwards it to the MCC for investigation and response.
• The TennCare Oversight Division will send the Provider written notification of this referral.
• The MCC must respond in writing to both the Provider and the TennCare Oversight Division by a set deadline to avoid assessment of Liquidated Damages or other appropriate penalties.
• If a Request for Independent Review is received that is not eligible for Independent Review, the Request will be processed as a Provider Complaint.

• Submit a written complaint by facsimile or secure/encrypted email delivery. If you must send by surface delivery, please send an encrypted CD or thumb drive by U.S.P.S, FedEx, UPS. etc. and email or fax the password. Or, use an SFTP account.
• Provide a summary of the problem. Include as much supporting information as possible, including copies of claims and remittance advices and other denial correspondence from the MCC.

If a Complaint concerns claims regarding multiple enrollees, the claims should be listed on an Excel spreadsheet with identification of the enrollee(s) by name, date of birth or SSN, and the date(s) of service. The Excel spreadsheet should be submitted in electronic format.

If a Complaint contains Protected Health Information (“PHI”), send it by surface or fax delivery, unless the Provider has HIPAA compliant securely encrypted email delivery system.

PHI includes any patient identifying information or protected health information, including the patient’s name and address.

The link to the TennCare Oversight Division’s email address can be found at: https://www.tn.gov/commerce/tenncare-oversight/contact.html

The Provider may seek other legal or contractual remedies; or, if the dispute concerns a TennCare services claims payment, the Provider can request the dispute be sent to an Independent Reviewer for resolution.

Effective 1/1/21, a CoverKids payment dispute will be eligible.

The Provider should notify the TennCare Oversight Division in writing if the MCC sends a satisfactory response promising to pay a claim or promising some other relief and then fails to do as represented.

The TennCare Oversight Division will require the MCC to show proof that the MCC has done what it promised to avoid assessment of liquidated damages or other appropriate penalty.

You can send electronically to the TennCare Oversight Division by:
Fax: 615-401-6834
Email TennCare.Oversight@tn.gov

If you have questions, you may call 615-741-2677 for assistance.

More information about the Complaint process can be found at: https://www.tn.gov/commerce/tenncare-oversight/mco-dispute-resolution/provider-complaint-process.html

A surface delivery Complaint can be submitted to:

Compliance Office
TennCare Oversight Division

TN Department of Commerce & Insurance
500 James Robertson Pkwy.
Nashville, TN 37243-1169