Skip to Content

TennCare Oversight Division

Prompt Pay Compliance Reports

 

The TennCare Oversight Division of the Tennessee Department of Commerce and Insurance determines prompt payment compliance of health maintenance organizations (HMOs), prepaid limited health service organizations (PLHSOs), and third party administrators (TPAs) 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 or managed care company (MCC) 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 TPAs January 2013 through Current Testing

 

HMOs and TPAs January 2011 through December 2012

 

HMOs, PLSHOs and TPAs January 2009 through December 2010

 

HMOs, PLSHOs and TPAs January 2008

 

HMOs, PLHSOs and TPAs 2006-2007

 

Pharmaceutical Benefits Manager 2006 to September 2008

 

HMOs and PLHSOs

 

Prompt pay compliance 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

 

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

 

Pharmacy Benefit Manager

 

The sole pharmacy benefit manager (PBM), a TPA, is contractually required to meet the following prompt pay compliance requirements for TennCare processed claims through September 30, 2008:

 

  • 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.

 

Beginning October 1, 2008, TennCare contracted with a different pharmacy benefit manager. Contractual prompt pay complaince requirements were updated to the following:

 

  • The Contractor shall pay within ten (10) calendar days of receipt one hundred percent (100%) of all clean claims submitted by network and non-network providers through POS and batch electronic claims submission.

 

Non-Emergency Transportation

 

During 2008, MCCs 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 TennCare HMos are required to process 90% of clean CHOICES claims submitted electronically within 14 days of receipt. Additionally, the TennCare HMOs are required to process 99.5% of clean CHOICES clams submitted electronically within 21 days of receipt

 

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.

 



Unless otherwise indicated, files are Adobe Reader® Files [pdf], 6.0 or higher. You may need to DOWNLOAD a free copy of Adobe Reader® be able to view these files.