Medical Billing Company in Tennessee | TennCare's Managed Care Model

Tennessee runs one of the most concentrated Medicaid managed care markets in the country. There's no traditional fee-for-service TennCare claim path. Nearly all of TennCare's 1.4 million members are enrolled in one of three Managed Care Organizations: BlueCare Tennessee, UnitedHealthcare Community Plan of Tennessee, or Wellpoint Tennessee (formerly Amerigroup). A fourth plan, TennCare Select, covers defined special populations under a separate arrangement. Each MCO negotiates its own fee schedule, prior authorization rules, and claims edits. A denial pattern that clears BlueCare doesn't automatically clear UnitedHealthcare or Wellpoint, and billing teams unfamiliar with this structure often lose time re-working claims against the wrong MCO's rules.

TennCare pays for roughly half of all births in Tennessee, which makes OB-GYN and pediatric billing volume unusually high relative to other states. If a covered service is denied, TennCare members and providers can call 1-800-878-3192 within 60 days to file a medical appeal directly. Providers don't have to exhaust the MCO's internal grievance process first. Mediknocx's coding and denial management teams track these MCO-specific edits alongside commercial payer rules from BlueCross BlueShield of Tennessee, Cigna, and regional employer plans active across the state.