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Tennessee - Case Management Service — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-10

In Tennessee, Case Management Services for Medicaid Home and Community-Based Services (HCBS) are primarily delivered through the state's managed care system under the TennCare CHOICES and Employment and Community First (ECF) CHOICES programs. The Tennessee Department of Finance and Administration, Division of TennCare, oversees these programs, but the actual delivery and contracting of case management (often referred to as care coordination or support coordination) is managed by the contracted Managed Care Organizations (MCOs) and the Department of Intellectual and Developmental Disabilities (DIDD).

The most significant structural precondition for providing this service in Tennessee is that standalone case management is generally not enrolled as an independent fee-for-service provider type for new applicants. Instead, providers must secure a contract with one of the state's designated MCOs (BlueCare, UnitedHealthcare Community Plan, or Wellpoint) or be an approved DIDD provider for specific legacy waivers. Prospective providers must first enroll through the TennCare Provider Registration portal to obtain a Medicaid ID, but this alone does not guarantee the ability to bill for case management without an MCO network contract.

1. Service Definition and Scope

Case Management (or Care Coordination/Support Coordination) in Tennessee involves assessing a member's needs, developing a person-centered support plan, and coordinating and monitoring the delivery of HCBS and other medical or social services. The service ensures that individuals receiving long-term services and supports (LTSS) through TennCare CHOICES or ECF CHOICES remain safely in the community.

The scope includes continuous monitoring of the member's health, safety, and welfare, facilitating access to community resources, and adjusting the care plan as the member's needs change. In the managed care framework, MCOs often employ their own care coordinators or contract with specialized entities to perform these functions.

2. Regulatory and Oversight Agencies

The primary oversight agency for Medicaid in Tennessee is the Division of TennCare, which administers the 1115 Demonstration Waiver encompassing the CHOICES and ECF CHOICES programs. TennCare sets the overarching rules, policies, and quality standards for all Medicaid services.

For populations with intellectual and developmental disabilities, the Department of Intellectual and Developmental Disabilities (DIDD) partners with TennCare to oversee service delivery and provider qualifications. Providers must also interact with the specific MCOs that manage the day-to-day administration of the benefits.

3. Gatekeeping Prerequisites: Who Can Even Apply

The most critical gatekeeping prerequisite in Tennessee is the managed care contracting requirement. TennCare operates its LTSS programs under a managed care model, meaning that obtaining a TennCare Medicaid ID does not automatically allow a provider to bill for services. Providers must be accepted into the provider network of one or more of the state's contracted MCOs.

Additionally, for services overseen by DIDD, providers must go through the DIDD provider enrollment process and meet specific credentialing requirements before they can contract with the MCOs for ECF CHOICES. There is no open fee-for-service enrollment for standalone case management for new HCBS waivers.

4. Licensure and Certification Requirements

Tennessee does not issue a specific "Case Management Agency" license through the Department of Health for HCBS providers. Instead, the authority to provide these services is granted through certification by DIDD (for I/DD populations) and credentialing by the MCOs.

Providers must meet the specific qualification standards outlined in the approved 1115 waiver and the MCO provider manuals, which generally require organizational competency, financial stability, and adherence to state and federal HCBS settings rules.

5. Medicaid Provider Enrollment

All prospective providers must enroll through the TennCare Provider Registration portal (PDMS) to obtain a TennCare Medicaid ID. This ID is a prerequisite for contracting with any MCO. The enrollment process requires submitting business information, ownership disclosures, and NPI details.

During enrollment, providers must select the appropriate provider type and specialty codes that align with HCBS and care coordination services. The portal is entirely web-based, and paper applications are generally not accepted.

6. Staffing, Training and Background Checks

Staff providing care coordination or support coordination must meet specific educational and experience requirements set by TennCare and DIDD. Typically, this requires a bachelor's degree in a human services field or a registered nurse (RN) license, along with relevant experience in LTSS.

All staff must undergo comprehensive background checks, including state and national criminal history checks, and checks against the Tennessee Abuse Registry and federal exclusion lists (OIG LEIE).

7. Documentation, Policies and Records

Providers must maintain comprehensive records for each member, including the initial and ongoing assessments, the person-centered support plan, and detailed progress notes for all contacts and interventions. Documentation must clearly show that services are delivered in accordance with the approved plan.

Agencies must also have robust internal policies covering critical incident reporting, grievance procedures, HIPAA compliance, and quality assurance. MCOs and DIDD conduct regular audits to ensure compliance with these documentation standards.

8. Billing, Rates and Claims

Because case management is delivered through a managed care model, billing is submitted directly to the contracted MCOs rather than to the state's fee-for-service MMIS. Providers must use the specific procedure codes and modifiers outlined in their MCO contracts.

Rates for care coordination are established by the MCOs, often based on a per-member per-month (PMPM) capitated rate or specific fee schedules negotiated during the contracting process. Providers must submit claims electronically using standard 837 formats or MCO-specific portals.

9. Approval Sequence and Timeline

The approval process begins with registering the business and obtaining an NPI. The provider then applies for a TennCare Medicaid ID through the PDMS portal, which can take several weeks to process.

Once the Medicaid ID is issued, the provider must apply for network inclusion with the MCOs (and DIDD, if applicable). The MCO credentialing and contracting phase is the longest part of the process and can take 90 to 120 days or more, depending on network adequacy needs.

10. Common Denials and Survey Findings

Applications for a TennCare Medicaid ID are frequently delayed or denied due to incomplete ownership disclosures or mismatched information between the IRS, NPPES, and the state application.

At the MCO level, the most common reason for denial is a "closed network," where the MCO determines it already has adequate capacity for care coordination services in a specific region. During audits, common findings include missing signatures on person-centered plans and failure to report critical incidents within required timeframes.

11. Key Contacts and Resources

Prospective providers should utilize the TennCare website and the specific MCO provider portals for the most current manuals, forms, and contact information. The TennCare Provider Registration page is the starting point for obtaining a Medicaid ID.

For services involving the I/DD population, the DIDD website provides essential information on provider requirements and the ECF CHOICES program.

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