The TennCare Oversight Division of the Tennessee Department of Commerce and Insurance determines prompt payment compliance of health maintenance organizations, prepaid limited health service organizations, and third party administrators that process TennCare claims.

The results of testing since January 2006 are linked below.

Please note that an analysis by month is provided for each organization for all TennCare claims processed. Additional analyses is provided for an organization for the following circumstances:

• The organization has more than one contract with the TennCare Bureau
• The organization has subcontracted with a vendor to process a specific claim type (ex: Vision)

HMOs and PLHSOs

Prompt pay compliance requirements are defined by Tenn. Code Ann. § 56-32-226(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.

DBM

TennCare's contract with its Dental Benefit Manager requires that the DBM also process claims in accordance with the same statutory standard as HMOs and PLHSOs.

PBM

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

The Contractor shall pay within twenty (20) calendar days of receipt ninety-five percent (95%) of all clean claims submitted by network and non-network pharmacy providers through POS, batch electronic and paper claims submission.

Thereafter, the Contractor shall pay the remaining five percent (5%) of clean claims within ten (10) calendar days.

Non-Compliance

If an HMO or PLHSO 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.