Provider Complaint Process
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1 TDCI TennCare Oversight Division Provider Complaint Process A Summary for TennCare Providers April 18, 2013
2 Who is the TennCare Oversight Division? We are the State agency that regulates TennCare program managed care companies. We assist in the regulatory oversight of Tennessee Medicare Advantage Special Needs Plans for Medicare/Medicaid Dually Eligibles ( MA SNPs and/or D-SNPs ) We are not part of the TennCare Bureau. We are located in the Department of Commerce & Insurance.
3 What is the TennCare Oversight Division Authority to do this? The Tennessee Code HMO law; The Contracts between TennCare and the TennCare Managed Care Companies (MCCs); and The Medicare Improvement for Patients and Providers Act of 2008 ( MIPPA ) The Contracts between TennCare and the Tennessee Medicare Advantage Special Needs Plans (MA SNPS).
4 What does the Division Do? Review & approve/disapprove provider agreement templates, unique provider agreements, and provider manuals for TennCare and MA SNP MCCs. Review & approve TennCare Program subcontractor agreements and operational relationships. Oversee financial solvency of the TennCare MCCs Examine, review & test for TennCare Program claims payment promptness and accuracy
5 What does the Division do? continued Process TennCare and MA SNP Provider Complaints to facilitate complaint resolution in an informal setting Administrative support for the TennCare Provider Independent Review Process Process enrollee complaints that need to be forwarded to the TennCare Bureau or the MCCs for resolution
6 What is the TennCare Oversight Division Provider Complaint Process? A process available to Providers of TennCare/MA SNP services who have a complaint against a TennCare or MA SNP managed care company ("MCC"). This process is free. The Division requires MCCs to respond to complaints from providers concerning operational and claims disputes in a timely manner. The Division uses information regarding disputed claims and other MCC operations to monitor and examine MCC compliance.
7 What kinds of Provider Complaints can be sent? 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 questions about MCC policy and procedures
8 What about non-tenncare Program Provider Complaints? Complaints about non-tenncare health plans regarding payment disputes for services should be directed to the TDCI Insurance Division Consumer Insurance Services Section at: But, complaints about Medicare Advantage Special Needs Plan services payment disputes for services rendered dually eligible TennCare members should be directed to the TDCI TennCare Oversight Division.
9 TDCI TennCare Oversight has web site information about the Provider Complaint Process Information about this provider complaint process is located at: The web site has a Provider Complaint form to assist providers wanting to submit a complaint. Send Provider Complaints by facsimile to ; or, by surface delivery to: TennCare Oversight Division 500 James Robertson Parkway, 11th Floor Nashville, TN 37243
10 How does the Provider Complaint Process work? When a Complaint is received, the Division forwards it to the MCC for investigation and response. The Division will send the Provider written notification of this referral. The MCC must respond in writing to both the Provider and the Division by a set deadline to avoid assessment of Liquidated Damages or other appropriate penalty. If a Request for Independent Review is received that is not eligible for Independent Review, the Request will be processed as a Provider Complaint.
11 How can a Provider submit a Complaint about an MCC? Submit a written complaint by surface delivery, facsimile or secure/encrypted electronic delivery. 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.
12 How can a Provider submit a Complaint about an MCC? (Continued) 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 and Date of Birth or SSN and the date(s) of service. The Excel spreadsheet should be submitted in electronic format, i.e. on a CD.
13 How can a Provider submit a Complaint about an MCC? (Continued) If a Complaint contains Protected Health Information ( PHI ) it should be sent by surface or facsimile delivery unless the Provider has a HIPAA compliant secure delivery system. PHI includes any patient identifying information, including the patient s name There is a HIPAA compliant link on the TDCI TennCare Oversight Division web site that can be used at:
14 What can a Provider do if not satisfied with the Response to the Provider Complaint? The Provider may seek other legal or contractual remedies; or, if the dispute concerns a TennCare services claims payment dispute the Provider can request the dispute be sent to an Independent Reviewer for resolution.
15 What can a Provider do if the MCC fails to do what it promises? Notify the 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 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.
16 Where do I send the Provider Complaint? A provider complaint can be submitted to: Compliance Office TennCare Oversight Division TN Department of Commerce & Insurance 500 James Robertson Parkway, 11 th Floor Nashville, TN
17 Where do I send the Complaint? (Continued) A provider complaint can be submitted by facsimile to: If a Provider has questions, the Provider may call for assistance. More information about the Complaint process can be found at:
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