TDCI TennCare Oversight Division Provider Complaint Process

1. TDCITennCare Oversight DivisionProvider Complaint Process A Summary for TennCare Providers February 17, 2011

2. Who is the TennCare Oversight Division? • We are located in the Department of Commerce & Insurance • We are the State agency that regulates TennCare program managed care companies. • Our authority comes from the Tennessee Code and the Contracts between TennCare and the TennCare Program Managed Care Companies (MCCs). • We are not part of the TennCare Bureau

3. What does the Division Do? • Review & approve/disapprove provider agreement templates, unique provider agreements, and provider manuals • Review & approve subcontractor agreements and operational relationships • Oversee financial solvency of the MCCs • Review & test for claims payment promptness and accuracy

4. What does the Division do?continued • Process provider complaints to facilitate complaint resolution in an informal setting • Administrative support for Independent Review Process • Process enrollee complaints that need to be forwarded to the TennCare Bureau for resolution

5. What is the TennCare Oversight Division Provider Complaint Process? • A process available to Providers of TennCare services who have a complaint against a TennCare 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 TennCare MCC compliance.

6. 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

7. What about non-TennCare Program Provider Complaints? • Complaints against non-TennCare health plans regarding payment disputes for services should be directed to the TDCI Insurance Division Consumer Insurance Services Section at: http://tn.gov/commerce/insurance/complaint.shtml • However, you can send a complaint to the TennCare Oversight Division concerning Medicare services payment disputes for services rendered dually eligible TennCare members enrolled in: UnitedHealthcare Community Plan Medicare Advantage SNP Plan AmeriGroup Community Care Medicare Advantage SNP Plan

8. 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. • If a Request for Independent Review is received that is not eligible for Independent Review, the Request will be processed as a Provider Complaint.

9. How can a Provider submit a Complaint about an MCC? • Submit the 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.

10. 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.

11. 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 email delivery system. • PHI includes any patient identifying information, including the patient’s name • There is a HIPAA compliant email link on the TDCI TennCare Oversight Division web site that can be used at: http://tn.gov/commerce/tenncare/contact.shtml

12. What can a Provider do if not satisfied with the Response? The Provider may seek other remedies, including requesting a claims payment dispute be sent to an Independent Reviewer for resolution or pursuing other available legal or contractual remedies.

13. 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.

14. 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, 11th Floor Nashville, TN 37243-1169

15. Where do I send the Complaint?(Continued) A provider complaint can be submitted by facsimile to: 615-532-8872 If a Provider has questions, the Provider may call 615- 741-2677 for assistance. More information about the Complaint process can be found at: http://tn.gov/commerce/tenncare/PCIR.shtml