TennCare Provider Pop Quiz

Welcome to the TennCare Provider Pop Quiz page. This interactive quiz is designed to challenge your understanding of real-life healthcare scenarios involving TennCare. Each question is details a common potential scenario, ensuring that you gain a deeper understanding of how TennCare functions in various healthcare settings.

Question: Mr. Jones lives in Covington, TN. He is driving down the street on a beautiful spring morning in April and sees a new physician practice has opened close to his home. He is a BlueCare member and when he called the practice, he was told they are not contracted with BlueCare but are contracted with UHCCP. He would like to switch doctors to this practice. Can Mr. Jones call TennCare and change MCOs from BlueCare to UHCCP?

Answer: No.

Why: MCO Change period for West TN is March.

Question: Ms. King lives in Millington, TN. Ms. King is a UHCCP member and knows the MCO Change Period for West TN is in March. She would like to change her MCO to BlueCare. Ms. King calls TennCare on March 7th to change her MCO from UHCCP to BlueCare. What will her effective date be with BlueCare?

Answer: Effective date with BlueCare will be May 1st.

Why: TennCare enrollees in West TN have from March 1st – March 31st to change MCOs. TennCare processes all change requests during the month of April, so MCO change requests will be effective the first of the following month which would be May.

Question: Mr. Green is a BlueCare member living in Knoxville. He has gone to see his PCP for his annual flu shot in September. Mr. Green sees a sign posted at the check‐in window which states his PCP will no longer be in‐network with BlueCare on January 1st. He knows the office will still be in‐network with UHCCP. Mr. Green wants to continue seeing his current PCP. Can he call TennCare and change MCOs?

Answer: No.

Why: This does not constitute a medical hardship. BlueCare has other PCPs in network and meet TennCare network access standards. Only way Mr. Green could change MCOs outside the East TN change period of July is if he met all 6 medical hardship criteria.

Question: I didn’t know James Reed had TennCare when he came to my office. May I bill him since he didn’t tell me?

Answer: No.

Why: It is the provider’s responsibility to determine whether or not a patient is a TennCare enrollee. Providers can verify a TennCare enrollee’s eligibility by logging onto TennCare Online Services, calling the TennCare Provider Services number or calling the individual’s MCC. See TennCare Rules 1200‐13‐13‐.08(6)(f) and 1200‐13‐14‐.08(6)(f).

Question: On March 18th, Rex Thomas applied for SSI. On April 5th, Dr. Jones treated Rex for a sprained wrist. On September 16th, TennCare learned that Rex was eligible for SSI and therefore TennCare and his eligibility was retroactive to March 18th. On September 17th, TennCare sends Rex’s enrollment information to his assigned MCO. What is the start date of the timely filing clock?

Answer: September 17th.

Why: In this example, Dr. Jones has 120 days to file his claim with the MCO. The start date for the 120 day period is September 17th (date his MCO learned of Rex’s enrollment) rather than the April 5th (date that Dr. Jones treated Rex). Dr. Jones is not penalized for the time when Rex’s eligibility status was unknown.

Question: In my office, we bill patients who don’t show up for their appointments. Is that a problem if the patient is on TennCare? Answer: Yes.

Why: TennCare providers are prohibited from billing enrollees or MCCs for missed appointments. See TennCare Rules 1200‐13‐13‐.08(6)(h) and 1200‐13‐14‐.08(6)(h).

Question: My patient, Rick Matthews, has TennCare but also has other insurance. I have tried to bill Rick’s insurance company, but they won’t pay because Rick won’t sign something they sent him attesting to the fact that I treated him. May I bill Rick?

Answer: Yes.

Why: When a TennCare enrollee has third party coverage but refuses to comply with the requirements of the third party carrier, the particular item or service that he received is considered “non‐covered” by TennCare. The provider may bill for non‐covered services. See TennCare Rules 1200‐13‐13‐.10(1)(n) and 1200‐13‐14‐.10(1)(n).

Question: I am providing eyeglasses to Pam Brown. Pam would like to have some special frames with a designer logo. May I “balance bill” Pam’s parents the difference between what TennCare would pay for the eyeglasses and what the special frames cost? Answer: No.

Why: TennCare payment is payment in full. See TennCare Rules 1200‐13‐13‐.08(1) and 1200‐13‐14‐.08(1).

Question: Tommy Butler’s mother has asked me to fill out a medical form that Tommy needs to be able to go to camp. I charge my private pay patients $15 for filling out medical forms like this. Tommy has TennCare. May I charge Mrs. Butler?

Answer: No.

Why: TennCare considers that the payment made to the provider for the service he has furnished includes filling out forms. It does not matter whether the forms are filled out during an appointment or after the fact when the provider receives a request from the enrollee or the enrollee’s responsible party.

Question: I am not registered with TennCare for any purpose, and I accept no TennCare payments. Do I have to abide by TennCare rules regarding billing TennCare patients?

Answer: No.

Why: TennCare has no authority over the actions taken by providers who are not registered with TennCare for any purpose and who accept no TennCare payments.