Tennessee Pharmacists Association

Medical Credentialing, Contracting, and Billing Resources

In Tennessee, pharmacists have many avenues to seek reimbursement for the services they provide. Progressive laws and regulations within the state allow for reimbursement for not only traditional pharmacy-based dispensing services but also clinical services reimbursable under insurance’s medical benefits.

For those interested in providing and billing for clinical services, follow the steps below.

The first step in becoming credentialed as a medical provider is to obtain a personal NPI number. It’s important to note that it must be an individual NPI number and not a pre-existing pharmacy NPI.

Pharmacists are encouraged to obtain professional liability insurance coverage of at least one million dollars ($1,000,000). Pharmacists, physicians, advanced practice nurses, and physician assistants engaging in collaborative pharmacy practice must each possess professional liability insurance coverage of at least one million dollars ($1,000,000) per occurrence.

TPA endorses Pharmacists Mutual as a preferred partner.

Pharmacists in Tennessee have multiple pathways to providing services, including through traditional pharmacy dispensing models, independently for certain disease states and conditions, or through Collaborative Pharmacy Practice Agreements (CPPAs) with another provider.

These pathways allow each community to be evaluated for services and the level of care they would benefit from. Review community needs and quality metrics before deciding what level of care to provide. Here are a few examples to assist:

In 2024, Tennessee-licensed pharmacists’ scope of practice expanded to allow for independent prescribing authority for certain classes of medications. Click here for more information on Tennessee-licensed pharmacists independently leading care services, including assessments and furnishing of medications.

“Collaborative pharmacy practice” is the provision of patient care services through a valid, executed collaborative pharmacy practice agreement (CPPA) between one or more Tennessee-licensed pharmacists and one or more Tennessee-licensed prescribers.

  • Through a diagnosis driven CPPA, pharmacists in Tennessee can provide many services that the collaborating provider allows for, given it is within the collaborating provider’s scope of practice.
  • Through a non-diagnosis driven CPPA, pharmacists can provide preventative care services.
  • Through non-patient specific protocols, pharmacists can provide services for hormonal contraception and opioid antagonists.

For those ready to launch a CPPA-driven practice, review this comprehensive checklist! Also, review more information on Collaborative Pharmacy Practice Resources in Tennessee.

For more information on providing individual services, click the links below:

After identifying the services to be provided, the next step is becoming credentialed as a medical provider to be reimbursed for these services. Through Public Chapter 82, Tennessee was one of the first states in the country to mandate commercial health plans’ reimbursement of pharmacists as providers.

While not required by law, TennCare also offers a process for pharmacists to become medically credentialed. This process requires a pharmacist to register as a TennCare provider before completing a CAQH profile. TennCare provides reimbursement pathways for both medical benefits and pharmacy benefits.

To complete the medical credentialing process, pharmacists must utilize a credentialing platform, such as CAQH or Pharmacy Profiles, to become recognized as a medical provider with commercial health plans.

CAQH:

  • Recognized in all 50 states and by over one thousand health plans, CAQH is a single-source platform that collects all the information required by health plans to recognize a medical provider. See Tennessee requirements for CAQH.
  • TPA has developed a step-by-step tutorial for completing a CAQH profile.
  • Once your profile is complete, you will have the option to either leave it “public” or allow only select health plans to view it. This is important to consider when proceeding to the next step in the process.
  • Note: Verification of credentials may take up to 120 days

After credential verification, pharmacists must enroll as medical providers with each health plan they plan on billing for reimbursable services. Each plan requires individual enrollment for reimbursement of services and will have different requirements and processes.

This may require additional contracts with the health plans or amendments to current pharmacy contracts.

Below are examples of health plans that reimburse for pharmacist-provided services in Tennessee. Click the links below to learn how to enroll.

Commercial Plans

Medicaid MCOs

For further assistance, TPA has created FAQs to review some of the more common issues our members have faced. See the FAQs at the bottom of this webpage.

After successful enrollment, it’s now time to bill for services that the pharmacist is providing. TPA offers a billing guide in conjunction with the Washington State Pharmacy Association (WSPA) for purchase. TPA recommends CPESN services to assist with understanding the billing codes available to pharmacists providing medical services.

Billing codes may be submitted manually by completing CMS form 1500 and other similar forms, but there are several electronic medical billing platforms that allow for increased efficiency and accuracy for capturing claim data. These include, but are not limited to:

Considerations when deciding which medical billing platform is right for your practice include:

  • Technology and service costs
  • Audit protections
  • Documentation capabilities
  • Follow up capabilities with patients
Frequently Asked Questions
  • Clearly Identify Yourself: When contacting the health plans, clearly state that you are a pharmacist seeking to enroll as a medical provider to provide medical services. Emphasize that you are not calling about pharmacy benefits but rather about provider enrollment.
  • Ask for the Correct Department: Politely request to be connected to the department responsible for provider enrollment or credentialing. This department typically handles the enrollment of medical providers rather than pharmacy benefits.
  • Provide Specific Information: Be prepared to provide specific information about your credentials, licensure, and the services you intend to provide. This will help streamline the enrollment process and ensure you are directed to the appropriate department.

You’ll likely need to amend or obtain a new contract because pharmacy contracts typically cover pharmacy services while you’re seeking to provide clinical services under the medical benefits of the health plan. Here are a few reasons why:

  • Scope of Practice: Pharmacy contracts are generally tailored to cover services related to dispensing medications and managing pharmacy benefits. If you’re looking to provide clinical services, you’ll need a contract that specifically allows for these services under the medical benefits.
  • Legal and Regulatory Compliance: There may be legal or regulatory requirements that necessitate a separate contract for providing clinical services under the medical benefits of the health plan.
  • Reimbursement Arrangements: Reimbursement rates and arrangements for clinical services may differ from those for pharmacy services. Having a separate contract allows for clear delineation of reimbursement terms and ensures that you’re properly compensated for the clinical services you provide.

While having multiple contracts with the same payer may seem redundant, each contract serves a distinct purpose based on the services being provided and the corresponding reimbursement arrangements. It’s essential to work with the payer to ensure that your contracts accurately reflect the services you intend to offer and that you’re properly credentialed and reimbursed for those services.

  • Patient Population: Analyze the demographics of your patient population. Which insurance plans do they commonly have? Contracting with the most prevalent payers among your patients can ensure better access to care.
  • Organization’s Preference: Consider your organization’s goals and preferences. Some practices prefer to work with a wide range of payers to maximize patient access. In contrast, others may focus on fewer, higher-reimbursing payers to streamline administrative processes.
  • Contract Terms: Evaluate the terms of the contracts offered by each health plan. Look at reimbursement rates, administrative requirements, and other factors that may impact your practice’s financial health and operational efficiency.

Note: Remember that you can utilize your credentialing platform to choose to only allow certain plans access to your platform based on your preferences and priorities.

Some insurance companies may charge a fee for processing the contracting application, while others may not. It’s important to inquire about any potential fees during the initial contact.

The contracting process can take anywhere from a few weeks to several months, depending on the health insurance company’s procedures and the completeness of your application.

Contracts typically need to be renewed periodically, often every one to three years. Renewal may involve updating your documentation and possibly renegotiating terms.

Current state law only mandates commercial health plans to recognize pharmacists as medical providers. However, there are opportunities within both Medicaid and Medicare to become contracted as providers to provide services. The list of eligible services may expand with future state and federal legislation.

While many pharmacists can apply, some insurers may have restrictions based on the type of services offered or the setting in which you practice (e.g., community pharmacy vs. hospital pharmacy).

Yes, credentialing typically needs to be renewed periodically, often every two to three years. Renewal may require submitting updated documentation and possibly undergoing a re-evaluation process.

Key features include medication management, clinical documentation, patient scheduling, billing and coding capabilities, secure messaging, reporting and analytics, and interoperability with other healthcare systems.

Additional Information

Visit TPA’s webpage on Practice-Based Resources (PBM Laws) for more information about Tennessee’s PBM enforcement efforts and pharmacy benefit reimbursement.

For pharmacists embedded in health-systems, see the AMA Resource, “Embedding Pharmacists Into the Practice.”

TPA has additional resources available for those that are looking for assistance; please contact TPA@tnpharm.org for more information