CLICK HERE TO VIEW ALL TPA PRACTICE-BASED RESOURCES
The current TennCare MTM Operations Manual continues to list the following monthly case rates: $55 for Targeted Disease State (juvenile asthma and diabetes), Medium High, and Moderate cases; $75 for High and Critical cases. Limit Exception (U4) reimbursement is based on the applicable level-of-care modifier.
However, a significant program change occurred by March 2022, when all three TennCare MCOs transitioned management of the MTM program from TennCare. TennCare discontinued operating the MTM pilot directly and continued MTM as a mandatory directed MCO payment program. MTM providers continue to provide Comprehensive Medication Reviews, Targeted Medication Reviews, and General MTM Encounter services to eligible TennCare members.
Current TennCare guidance directs pharmacists to the applicable BlueCare, UnitedHealthcare Community Plan, or Wellpoint provider manual for current MTM reimbursement and billing information.
GENERAL INFORMATION
REQUIREMENTS FOR PARTICIPATIONPharmacists must meet the following criteria to qualify as TennCare MTM pharmacists.
Collapse All
STEP 1: Get an NPI The pharmacist must have a valid Tennessee pharmacist license and an individual National Provider Identifier (NPI). The pharmacist must also maintain appropriate professional liability insurance as required by TennCare. Current TennCare MTM requirements specify professional liability coverage of at least $1,000,000 per occurrence and $3,000,000 aggregate. Pharmacists who do not already have an individual NPI should obtain one through the National Plan and Provider Enumeration System (NPPES) HERE. STEP 2: Get a TennCare Provider ID The participating pharmacist must acquire his or her own TennCare Medicaid ID. Information on provider registration and how to access the provider portal can be found on the TennCare Provider Registration website. STEP 3: Collaborate with PCMHs and HealthLink Organizations The MTM pharmacist must have a written formal Collaborative Practice Agreement (CPA) in place with a TennCare Patient-Centered Medical Home (PCMH) or Tennessee HealthLink (THL) organization. STEP 4: Complete the Credentialing Process Individual providers will submit information that will place them on the DataSpring (previously known as CAQH) roster for TennCare/Tennessee Medicaid. Information and links, including an FAQ document, can be found HERE. Once data is received from DataSpring and approved, a Medicaid ID will be assigned. It is also important to note that TennCare will automatically receive the provider’s profile data from DataSpring each time the provider makes an update. STEP 5: Enroll in MTM Provider Networks The MTM pharmacist must engage and complete the Managed Care Organizations (MCOs) credentialing and network agreements. Register on DataSpring for the networks listed below. The pharmacist will need to contact the three TennCare MCOs listed below and specifically request to be enrolled as a medical provider for the TennCare MTM Program. The provider manuals for the three TennCare MCOs administering the TennCare MTM Program are linked below: For specific health plan questions, the contact information for each MCO can be found HERE. STEP 6: Authorize the Care Coordination Tool (CCT) **NOTE: CCT is currently not being used as of Sept. 2026 due to a data breach The MTM pharmacist participating in the MTM program must document in the CCT and must complete the onboarding registration, training and access process for the CCT. After a CPA is in place, the pharmacist may initiate CCT registration by emailing the following information to TennCare.Pharmacy.AdobeSign@tn.gov. STEP 7: Agree to TennCare Privacy Policies Each user will be required to sign TennCare’s Acceptable Use Policy and Remote Access Request forms to ensure that health information is protected. STEP 8: Provide MTM Services and Submit Claims ALL registration steps listed above must be completed prior to providing MTM services and submitting claims for reimbursement. After completion, MTM services may be provided to patients, and claims may be submitted.
a.‑
For more information concerning provider registration, please email Provider.Registration@tn.gov or call 1-800-852-2683, option 5.
a.‑
The CPA establishes pharmacists to prescribing provider (supervising physician) expectations from scope of practice to documentation. See Section 17 in the Tennessee Board of Pharmacy rules.
b.‑
CPA guidance and minimum requirements
c.‑
Additional information about CPA requirements (on the TPA website)
d.‑
Access the list of TennCare PCMH organizations and THL organizations
a.‑
Click here to log in and complete the DataSpring process.
a.‑
Wellpoint Network Access
b.‑
United Healthcare Network Access
c.‑
BlueCare Network Access
a.‑
NPI
b.‑
TennCare/Medicaid ID
c.‑
Name of TennCare PCMH or THL Organization
d.‑
Name(s) of pharmacist(s)
e.‑
Email address (contact information)
f.‑
Copy of CPA attestation/addendum signed by supervising physician and pharmacist providing services
(CCT access will be granted after the MCO credentialing and network processes are completed.)
g.‑
The CCT tool enables providers to see real-time information about members in need of follow-ups, which will allow providers to help close gaps in care. At this time, those manual gaps in care closures will not contribute to the quality performance reported from the MCOs each quarter, unless a corresponding claim is received to verify the gap has been closed.