- +1 (773) 985-1869
- info@stream-rcm.com
- 14430 Ocean Point, El Paso, TX 79938
Medical billing for a Tennessee practice often means working with TennCare Medicaid plans, Medicare and commercial insurers, each with its own claim rules. Stream RCM provides medical billing services in Tennessee for doctors, clinics and specialty groups. Our AAPC-certified medical billers and coders check coverage, review patient records and assign the correct codes. We submit TennCare claims to each patient’s assigned plan and handle billing for Medicare, Medicare Advantage and private insurers, including BlueCross BlueShield of Tennessee, Cigna Healthcare, Ambetter of Tennessee and Aetna.
TennCare claims usually stall for four reasons: the wrong health plan on file, a late filing, a missing prior authorization (approval needed before care) or a Medicare crossover claim sent to the wrong payer. Since TennCare moved to managed care in 1994, most medical claims go through one of TennCare’s three health plans rather than directly to the state. Each plan processes its own claims, so a claim sent to the wrong plan comes back unpaid even when the patient has active coverage. Since January 1, 2024, crossover claims (the deductible and coinsurance left after Medicare pays) also go to the health plan.
TennCare Members
Health Plans
Filing Limit
Each specialty faces different coding and payer rules in Tennessee. Surgeons, pediatricians and behavioral health providers can fall under TennCare’s Episodes of Care program, which links payment to the cost and quality of care for a set condition or procedure. Primary care groups in the Patient-Centered Medical Home (PCMH) program earn extra payments from the health plans for meeting quality and cost goals. Rural health clinics and federally qualified health centers (FQHCs) are paid a set rate per visit under their own rules. Medicare also updated its 2026 payment rules, including adjustments to how certain procedures are valued. Our coders check which payer and program rules apply to each provider and service before a claim is sent.
Our medical billing specialists in Tennessee handle TennCare, Medicare and commercial insurance claims for solo physicians, group practices and clinics. Each account gets coders who know the rules of BlueCare, UnitedHealthcare Community Plan and Wellpoint.
Our medical billing and coding process in Tennessee follows the same 8 steps for every claim, from the first patient check to the final payment or appeal.
Patient Information
Insurance EligibilityClinical Coding
Complete Charge
Claim
Payment
Denial
A/R and PatientWe confirm each patient's legal name, date of birth, address, member ID and any other coverage. TennCare pays after other insurance, so Medicare and private plans are billed first. Under a law in effect since January 1, 2026, licensed Tennessee providers must accept electronic insurance cards issued by health insurers, so our intake checks cover both paper and digital cards.
Before each visit, we confirm active TennCare coverage, the assigned health plan and any Medicare coverage. We also check whether patients with both Medicare and TennCare have matching plans. Starting January 1, 2027, some full-benefit dual-eligible members whose Medicare D-SNP and TennCare plans do not match may be moved to Original Medicare. Learn more about our insurance eligibility verification services.
Our certified coders read each provider note and assign only the procedure codes (CPT and HCPCS) and diagnosis codes (ICD-10-CM) it supports. We review the National Correct Coding Initiative (NCCI) edits that apply to each claim and add a modifier (a two-character code that adds detail) only when coding rules and the provider's note support it. For Medicare patients, we also check the local coverage determinations (LCDs) from Palmetto GBA, Tennessee's Medicare contractor. These rules list when a service is medically necessary.
Missed charges never become claims, so we compare visit notes, procedure logs and superbills (visit charge sheets) with the charges in your system. Injections, supplies and add-on codes are frequent gaps. We also confirm where each service took place, because Medicare often pays a different rate for the same service in a hospital or facility than in an office.
We send TennCare claims to the plan listed in the patient's eligibility record. Original Medicare Part A and Part B claims go to Palmetto GBA, and Medicare Advantage claims go to the plan itself. Tennessee's prompt pay law generally requires state-regulated health insurers to pay clean claims within 21 days when filed electronically or 30 days on paper.
We post electronic remittance advice (ERA) and paper explanations of benefits (EOBs) one line at a time. Each TennCare health plan sets its own fee schedule, so a BlueCare payment against the BlueCare rate, not UnitedHealthcare or Wellpoint. For covered services, TennCare members can't bill TennCare members more than any allowed copay, so we adjust the remaining balance instead of sending a patient statement.
We find the reason for each denial first, then correct, resubmit or appeal the claim. For prior authorization denials, we also check the state's deadlines. Tennessee's Prior Authorization Fairness Act, in effect since January 1, 2025, covers most state-regulated health plans but not TennCare or self-funded employer plans. These plans must decide routine requests within 7 calendar days and urgent ones within 72 hours in most cases. A claim also can't be denied for missing approval if the requirement didn't exist on the date of service. Learn more about our denial management services.
For accounts receivable (A/R) follow-up, we sort open claims by filing deadline first, then by age and balance. Our team checks status in payer portals, calls when a status is unclear and sends corrected claims when required. Under Tennessee's prompt pay law, state-regulated insurers that pay a clean claim late may owe 1% interest per month, so we flag late payments and raise them with the payer.
The answer depends on the full cost of billing, not one employee’s salary. An in-house team needs pay, benefits, training, software and backup staff, plus time to keep up with TennCare and Medicare rule changes. When you outsource medical billing services in Tennessee, most of these costs become one fee based on your collections. The table below compares both options.
| Billing Area | In-House Billing | Outsourced to Stream RCM |
|---|---|---|
| Staffing | Hiring, payroll and coverage for time off | A certified billing team assigned to your account |
| Payer Rules | Staff follow TennCare, Medicare and insurer updates alone | Specialists who follow payer rule changes |
| Denial Work | Handled between front-desk and phone tasks | Each denial reviewed, then corrected or appealed |
| Cost Structure | Fixed salaries, benefits and software each month | A percentage fee based on monthly collections |
| Reporting | Limited to what your software shows | Real-time reports on claims, denials and A/R |
Practices looking for an RCM services company in Tennessee can choose single services or hand over the full revenue cycle.
Each claim is checked against payer and TennCare plan rules, filed electronically and tracked until the payer responds.
AAPC-certified coders assign CPT, HCPCS and ICD-10-CM codes and modifiers that match the provider's documentation.
Denied claims are sorted by reason so repeat errors are fixed at the source and appeals meet payer deadlines.
We track unpaid claims by age, filing deadline and balance, check payer updates and follow up regularly until each claim is paid or resolved.
We handle provider credentialing and enrollment with TennCare, its 3 health plans, Medicare and commercial payers, including revalidation.
Our remote billing team can support practices in any of Tennessee’s 95 counties. The cards below show TennCare enrollment and each county’s share of residents on TennCare, from the TennCare 2025 Annual Report.
Shelby County, covering Memphis and Germantown, had 241,398 TennCare members (26.3%), the highest member count in Tennessee.
Nashville sits in Davidson County, where 131,177 residents, or 17.8% of the population, were covered by TennCare.
Knoxville and Farragut are in Knox County, where 76,771 residents, about 15.0% of the county, had TennCare.
In Hamilton County, which includes Chattanooga, 65,820 people were enrolled in TennCare, or 16.9% of all residents.
Rutherford County recorded 62,892 TennCare members, or 16.0% of residents, across Murfreesboro, Smyrna and other nearby towns.
Montgomery County, home to Clarksville and part of Fort Campbell, had 45,363 TennCare members, 17.7% of residents.
Kingsport and the Tennessee side of Bristol are in Sullivan County, where 31,475 residents (19.5%) had TennCare.
Sumner County, with Gallatin and Hendersonville, had 30,090 TennCare members, a 13.9% share below the state's 19.7%.
Jackson is the largest city in Madison County, where 24.7% of residents, or 24,674 people, had TennCare.
Johnson City and East Tennessee State University sit in Washington County, which counted 23,713 TennCare members (17.2%).
Bradley County, centered on Cleveland, had 22,768 TennCare members, close to one in every five residents (19.9%).
Lebanon and Mount Juliet are in Wilson County, where 22,223 residents, or 12.9%, had active TennCare coverage.
Blount County, including Maryville and Alcoa, reported 20,737 TennCare members, which equals 14.3% of all county residents.
Williamson County, with Franklin and Brentwood, had the state's lowest TennCare share at 5.0%, or 13,858 members.
Hancock County, where Sneedville is the county seat, had 2,184 TennCare members, Tennessee's highest share at 32.1%.
These are the results Stream RCM reports across its client practices. Your results can differ based on payer mix, claim volume and the current state of your billing.
Our Tennessee billing services include eligibility checks, coding, charge entry, claim submission, payment posting, denial management and A/R follow-up. Provider credentialing is also available.
Yes. Providers register with TennCare first, and then each health plan signs its own contract with the provider. TennCare also requires providers to renew (revalidate) their enrollment on a set schedule.
Claims are due to the member’s health plan within 120 days of the date of service. When eligibility is approved after the visit, the 120 days start when the health plan learns of the enrollment.
Stream RCM pricing starts at 2.99% of monthly collections. Your exact rate depends on your specialty, claim volume and the services you choose.
State law requires each TennCare health plan to process 90% of clean claims within 30 days and 99.5% of all claims within 60 days. The Department of Commerce and Insurance checks compliance every month.
Compare each medical billing company in Tennessee on certified coders, TennCare and Medicare experience, clean claim and denial rates, reporting and pricing terms. Ask for sample reports and results from practices in your specialty.
Share your practice’s specialty and main billing concerns. Our team will review the issues you describe and discuss possible next steps for TennCare, Medicare or commercial claims.
Get a complimentary billing audit and discover potential revenue leaks, claim issues, and missed opportunities affecting your practice.
Find areas where your practice may be losing collectible revenue.
Get insights into your current billing and claims process.
Receive your audit without committing to a service.
Complete the short form and our billing team will review your request.
