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MANUALS, POLICIES & GUIDELINES

Your source for important information

Review the latest provider administration manuals, medical policies and guidelines to find information about how we deliver member benefits, how we determine medical necessity and other important decisions.

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INFORMATION FOR WORKING WITH US

Provider Administration Manual (PAM)

As discussed in our provider contracts, these manuals are your source for important information about our policies and procedures.

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PROMOTING MEDICATION ADHERENCE

Medication Therapy Management Program

The Medication Therapy Management (MTM) Program helps eligible members with medication management, including identifying, preventing and resolving medication interactions and other treatment-related problems. Review information from the Division of TennCare about the MTM Program and Care Coordination. We've also created a Medication Therapy Management Provider Operations Manual.

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MEDICAL POLICIES & MORE

See our coverage policies & guidelines

Find more information about our medical policies, utilization management guidelines and administrative services policies. You can also see newly approved policies and guidelines, and offer feedback on developing policies and updates.

We review requests based on medical necessity, and the guidelines used for reviews are applied in the following order:

  1. Division of TennCare
  2. BlueCross BlueShield of Tennessee Medical Policy
  3. MCG Cite Guideline Transparency
  4. Centers for Medicare & Medicaid Services

Medical Policies

Medical Policy Manual Draft Medical Policies Upcoming Medical Policies Medical Policy Appeals Process Provider Administered Specialty Medication Step Therapy Guide

Utilization Management Guidelines

Utilization Management Guidelines Upcoming Utilization Management Guidelines

Administrative Services Policies

Administrative Services Policies Draft Administrative Services Policies Upcoming Administrative Services Policies

Telehealth Guidelines

BlueCare Tennessee Telehealth Services BlueCare Tennessee Maternity Telehealth Guide Telehealth Approved Code List
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CLINICAL PRACTICE GUIDELINES

BlueCross BlueShield of Tennessee Clinical Practice Guidelines

BlueCross adopts and disseminates specific nationally recognized clinical practice guidelines for use by our network providers. The guidelines address acute and chronic medical services, and behavioral health services to assist practitioners in making appropriate health care decisions for specific clinical circumstances. It’s our intent to make resources available to our providers that will help in this endeavor. BlueCross attests that the text and format of these compendia haven’t been altered in any way, and that these resources shouldn’t be construed as a legal or required standard of care.

More information can be found in the U.S. Preventive Services Task Force Guide to Clinical Preventive Services. We hope this will be both convenient and helpful to you in caring for your patients. Paper copies of the guidelines are available upon request by calling (423) 535-6705.

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LANGUAGE INTERPRETATION

Foreign language assistance

Here are resources that may help if you need assistance with language interpretation when talking with patients. Note: These resources aren’t affiliated with or endorsed by BlueCare Tennessee, and fees for these services may apply.

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REGULATORY INFORMATION

Regulations guidance and Medicaid audit contractors

Learn more about working with the Division of TennCare and policies specific to Medicaid plans.

  • Division of TennCare

    TennCare is the State of Tennessee’s Medicaid program and is directed by the Division of TennCare. Services are offered through managed care organizations like BlueCare Tennessee. In addition to BlueCare Tennessee, there’s a Pharmacy Benefits Manager and a Dental Benefits Manager for dental services. Click here for more information.

  • Contractor Risk Agreement

    The Contractor Risk Agreement (CRA) details the terms BlueCare Tennessee must follow to operate a provider network and provide covered health services to TennCare enrollees.

  • Third-Party Liability Insurance

    Third-party liability (TPL) is a part of our contract that excludes payment for expenses covered by another medical plan. In most cases, BlueCare Tennessee is the payer of last resort, meaning providers should bill the third-party payer before billing us for services. You can read more about TPL and what this means for you in our Provider Administration Manual.

  • Medicare and Dual Special Needs Plan (DSNP) Crossover Claims

    Effective Jan. 1, 2024, we began processing Medicare and DSNP crossover claims. Please review our FAQs for Providers or the MCO Crossover Billing Training at tn.gov.

  • Payment Error Rate Measurement (PERM) Program

    The Improper Payments Information Act (IPIA) of 2002 (amended in 2010 by the Improper Payments Elimination and Recovery Act or IPERA) requires the heads of Federal agencies to annually review programs they administer and identify those that may be susceptible to significant improper payments, to estimate the amount of improper payments, to submit those estimates to Congress, and to submit a report on actions the agency is taking to reduce the improper payments. The Office of Management and Budget (OMB) has identified Medicaid and the Children’s Health Insurance Program (CHIP) as programs at risk for significant improper payments. As a result, CMS developed the Payment Error Rate Measurement (PERM) program to comply with the IPIA and related guidance issued by OMB. Learn more about the PERM Program on the CMS website.