Claims, Appeals & Provider Complaints

When a provider disagrees with an outcome of a claim, an appeal (also known as a reconsideration) can be submitted to the applicable TennCare Managed Care Organization (“MCO”). If the provider is not satisfied with the appeal/reconsideration outcome, a provider complaint may be filed with the Tennessee Department of Commerce and Insurance, TennCare Oversight. This provider complaint process is a courtesy provided to medical and transportation providers who have a complaint against a TennCare Managed Care Company ("MCC") or a Medicare Advantage Special Needs Plan (“MA-SNP”). Complaints may involve claims payment accuracy and timeliness, credentialing procedures, inability to contact or obtain assistance from the MCC/MA-SNP, miscommunication, or confusion around MCC/MA-SNP policy and procedures, etc. This process is also available for disputing annual Episodes of Care Reports.