Regulations Guidance and Medicaid Audit Contractors

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Bureau of TennCare

TennCare is the State of Tennessee's Medicaid program that provides health care for 1.2 million Tennesseans. TennCare services are offered through managed care entities such as BlueCare Tennessee. BlueCare Tennessee has served TennCare members since TennCare began. In addition to BlueCare Tennessee, there is a Pharmacy Benefits Manager for coverage of prescription drugs and a Dental Benefits Manager for provision of dental services to children under age 21.

TennCare Provider Links off-site link

Reporting Third Party Liability Insurance Updates

Medicare crossover payments are normally made by the Bureau of TennCare separately from the Managed Care Contractors. Rules 1200-13-13-.08(12) (b) and 1200-13-14-.08(12)(b) set forth the guidelines for timely filing for Medicare crossover claims Please contact TennCare Provider Services at 1-800-852-2683.

PERM

The PERM program measures improper payments in Medicaid and CHIP and produces error rates for each program. The error rates are based on reviews of the fee-for-service (FFS), managed care, and eligibility components of Medicaid and CHIP in the fiscal year (FY) under review. It is important to note the error rate is not a "fraud rate" but simply a measurement of payments made that did not meet statutory, regulatory or administrative requirements. FY 2008 was the first year in which CMS reported error rates for each component of the PERM program. (The Centers for Medicare and Medicaid Services)

The Centers for Medicare & Medicaid Services (CMS) is hosting PERM Provider Education Conference Call/ Webinars to provide an opportunity for the providers of the Medicaid and Children's Health Insurance Program (CHIP) communities in the Cycle 2 (FY2013) States to learn about PERM and their responsibilities during the PERM process. This is also an opportunity for you to ask questions and provide feedback to CMS and your state representatives.

For an overview on PERM, visit : PERM Overview [PDF, 382KB]

Recovery Audit Contractor

HMS is under contract with the State of Tennessee Bureau of TennCare as Tennessee's Medicaid Recovery Audit Contractor (RAC), pursuant to Section 6411 of the Patient Protection and Affordable Care Act of 2010. Accordingly, HMS is authorized to audit provider payments and associated financial records for Fee-For-Service and Medicaid Managed Care claims to identify underpayments and overpayments, and to recover any overpayments made to providers.

For additional information on HMS Medicaid RAC visit: http://www.medicaid-rac.com/ off-site link

For additional information on Medicaid RAC providers visit: http://www.medicaid-rac.com/providers/ off-site link

Contractor Risk Agreement

The Contractor Risk Agreement (CRA) describes the terms of agreement entered into by the Bureau of TennCare and BlueCare Tennessee to operate a provider network and provide covered health services to TennCare enrollees. (offsite link)

REFERENCES:

MCO Contractor Risk Agreements
Statewide Contractor Risk Agreement with Amendment 2 – July 1, 2015


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