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TennCare was the first statewide mandatory Medicaid managed care waiver in America. Care is delivered through three risk-based MCOs: BlueCare Tennessee, Amerigroup / Wellpoint, and UnitedHealthcare Community Plan. Tracking MCO-specific prior authorization rules, episode-of-care quality incentives, and formulary restrictions is vital.
BCBST commands leading private commercial market share and administers health benefits for state and local government employees. Practices must strictly adhere to BCBST proprietary medical policies, network tiers, and pre-service authorization requirements to prevent denials.
Tennessee shares Medicare Jurisdiction J with Georgia and Alabama under Palmetto GBA. Palmetto GBA rigorously monitors Local Coverage Determinations (LCDs) on minor surgical procedures, trigger point injections, physical therapy caps, and evaluation and management documentation.
Under Tennessee Code Annotated § 56-7-109, health maintenance organizations and commercial insurers must pay clean electronic claims within 21 calendar days and paper claims within 30 days. Claims unpaid within this statutory period accrue mandatory interest penalties. We track clearinghouse timestamps to enforce prompt claim adjudication.
Full-service billing and coding tuned specifically for BlueCross BlueShield of Tennessee (BCBST) contracts and Palmetto GBA (Jurisdiction J) Medicare coverage policies.
Learn MoreEnd-to-end RCM that tracks Tennessee payer pre-authorization turnaround, secondary crossovers, and fee schedule compliance.
Learn MoreProvider enrollment and roster alignment across Tennessee Medicaid programs, commercial networks, and hospital health systems.
Learn MoreTargeted historical audit analyzing 90 days of claims for Tennessee underpayments, modifier misalignments, and prompt pay interest.
Learn MoreFront-desk patient intake, real-time insurance verification, and prior authorization handling without local staffing overhead.
Learn MoreReal-time performance analytics benchmarking your collection velocity against Tennessee specialty peer averages.
Learn MoreHigh-intent patient acquisition for independent medical practices competing with consolidated hospital networks in Tennessee.
Learn More| Tennessee Payer Reality | The Generic Billing Trap | The MD Revenue Group Approach |
|---|---|---|
| TennCare 3 MCOs | Failing to maintain provider credentialing across BlueCare, Amerigroup, and UHC, resulting in out-of-network denials. | We synchronize provider rosters across all 3 TennCare health plans and verify active member assignment. |
| BCBST Market Dominance | Treating BCBST like an out-of-state Anthem plan, missing state employee health plan rules and fee schedule nuances. | We configure direct BCBST clearinghouse rules and track fee schedule compliance across all specialties. |
| Palmetto GBA JJ LCDs | Submitting outpatient injections or minor surgeries without verifying Jurisdiction J Local Coverage Determinations. | We pre-scrub claims against Palmetto GBA JJ LCD criteria and ensure correct modifier application. |
| T.C.A. § 56-7-109 Prompt Pay | Allowing electronic claims to exceed the 21-calendar-day prompt pay window without demanding interest penalties. | We log clearinghouse timestamps and aggressively pursue statutory interest on delayed payments. |
We analyze 90 days of recent claims data to uncover BlueCross contract shortfalls and Palmetto modifier mismatches.
Targeted workflow fixes to address local prior authorization delays, Medicaid hurdles, and timely filing bottlenecks.
We establish seamless clearinghouse connections with Palmetto, Medicaid, and commercial plans while your practice continues billing uninterrupted.
Transparent tracking toward 98%+ first-pass clean claim rate, under 32 average days in A/R, and maximized provider revenue.
Our Tennessee team untangled TennCare MCO provider roster issues, resolved Palmetto GBA modifier 25 denials, and reduced clean claim rejections below 2%.
See What We Can Recover For YouTennCare continues refining value-based purchasing benchmarks under its TennCare III waiver, rewarding primary care practices that meet chronic disease and maternal health targets.
Palmetto GBA continues targeted audits on provider groups billing level 4 and 5 established patient visits above regional peer group averages.
We audit specifically for BlueCross BlueShield of Tennessee (BCBST) fee shortfalls, TennCare Managed Care (BlueCare, Amerigroup, UHC) credentialing holdbacks, and Palmetto GBA (Jurisdiction J) Local Coverage Determinations.
