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Prompt Pay Compliance Reports

The TennCare Oversight Division of the Tennessee Department of Commerce and Insurance determines prompt payment compliance of managed care company (MCC), pharmacy benefit managers and dental benefit managers that process claims for the TennCare, CoverKids, and CoverRx programs through contracts with the Division of TennCare in the Tennessee Department of Finance and Administration. CoverKids provides self-funded health plan services, including certain pharmacy benefits, to eligible children under age nineteen (19), including unborn children who are covered from conception to birth.  CoverRx is the State’s pharmacy assistance program that provides limited pharmacy assistance through retail or mail order to eligible participants enrolled in the State’s Department of Mental Health and Substance Abuse Services Safety Net program and for other eligible adults ages nineteen (19) through sixty-four (64) needing access to prescription drugs for acute care and ongoing disease management.  The results of testing since January 2013 are linked below. Please note that an analysis by month is provided for each organization or MCC for all TennCare claims processed. Additional analyses are provided for an organization for the following circumstances:

• The organization has more than one contract with the Division of TennCare

• The organization has subcontracted with a vendor to process a specific claim type (ex: Vision)

January 2019 through Current Testing

TPAs January 2017 through December 2018

TPAs January 2015 through December 2016

TPAs January 2013 through December 2014

Health Maintenance Organizations

Prompt pay compliance for TennCare claims requirements are defined by Tenn. Code Ann. § 56-32-126(b)(1). This statute requires that 90% of claims for payment for services delivered to a TennCare enrollee, (for which no further written information or substantiation is required in order to make payment), are processed, and if appropriate paid within thirty (30) calendar days of the receipt of such claims and 99.5% of all provider claims are processed, and if appropriate paid within sixty (60) calendar days of receipt.

Dental Benefit Manager

The dental benefit manager is contractually required to meet the same statutory prompt pay compliance requirements as health maintenance organizations.

Pharmacy Benefit Manager

The pharmacy benefit manager is contractually required to meet the following prompt pay compliance requirements for TennCare and CoverRx processed claims:

The Contractor shall if appropriate, pay within fifteen (15) days of receipt one hundred percent (100%) of all clean claims submitted by network and non-network pharmacy providers through point of service and batch electronic claims submission.

Non-Emergency Transportation

During 2008, health maintenance organizations offering non-emergency transportation services were contractually required to process claims for these services as a subset in accordance with the same standards of Tenn. Code Ann. § 56-32-126(b)(1).

CHOICES

CHOICES is TennCare's program for long-term care services including care in a nursing home and certain services to help a person remain at home or in the community. Contractually, the health maintenance organizations are required to process 90% of clean CHOICES claims submitted electronically within 14 days of receipt. Additionally, the TennCare health maintenance organizations are required to process 99.5% of clean CHOICES clams submitted electronically within 21 days of receipt.

Employment and Community First CHOICES

Employment and Community First (ECF) CHOICES is TennCare’s program for people of all ages who have an intellectual or developmental disability. Services in the program help people with intellectual or developmental disabilities live as independently as possible at home or in the community, not in an institution. If the person lives at home with their family, the services help their family support them to become as independent as possible, work, and actively participate in their communities.  Contractually, the health maintenance organizations are required to process 90% of clean ECF claims submitted electronically within 14 days of receipt. Additionally, the health maintenance organizations are required to process 99.5% of clean ECF clams submitted electronically within 21 days of receipt.

NON-COMPLIANCE

If an HMO fails to meet the prompt pay standards and be forced to report on a monthly basis, any subsequent month in which they fail to comply with the prompt pay law will be penalized as allowed by the statute in an amount not to exceed ten thousand dollars ($10,000). Furthermore, the TennCare Bureau reserves the right to avail itself of any and all remedies afforded by state and federal law and the TennCare Contract.