Tennessee - Home Health Service — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-08-16

In Tennessee, Home Health Services provide intermittent skilled medical care, including nursing, physical therapy, occupational therapy, speech-language pathology, and medical social services, to homebound patients. These services are delivered under a physician-ordered plan of care and serve eligible Medicaid beneficiaries primarily through the TennCare CHOICES Long-Term Services and Supports waiver program.

The single biggest structural barrier to entry for a new home health provider in Tennessee is the Certificate of Need (CON) requirement. Before an agency can even submit a licensure application, it must secure an approved CON from the Tennessee Health Facilities Commission (HFC), a highly competitive and heavily scrutinized process that restricts new skilled entrants based on county-specific need and market saturation.

1. Service Definition and Scope

Home Health Services in Tennessee encompass a range of intermittent skilled clinical services provided in the patient's place of residence. The primary goal is the treatment of an illness or injury, helping the patient recover, regain independence, or manage a chronic condition.

These services are strictly regulated by state licensure rules and federal Medicare Conditions of Participation (42 CFR Part 484). Care must be ordered by a physician and delivered according to a comprehensive, regularly updated Plan of Care.

• Skilled Nursing: Intermittent care provided by Registered Nurses (RNs) or Licensed Practical Nurses (LPNs) under RN supervision, including wound care, injections, and disease management.
• Physical Therapy: Rehabilitation services designed to restore mobility, strength, and balance.
• Occupational Therapy: Therapeutic interventions to help patients regain the ability to perform activities of daily living (ADLs).
• Speech-Language Pathology: Diagnostic and therapeutic services for speech, language, cognitive, and swallowing disorders.
• Medical Social Work: Counseling, crisis intervention, and community resource coordination for patients and their families.
• Home Health Aide Services: Personal care and basic health assistance provided under the direct supervision of a skilled clinician.

2. Regulatory and Oversight Agencies

Oversight of home health agencies in Tennessee was restructured in July 2022. The independent Tennessee Health Facilities Commission (HFC) absorbed the health care facilities licensure program from the Department of Health and now handles both the Certificate of Need process and facility licensure.

Medicaid enrollment and managed care oversight are administered by the Division of TennCare. TennCare contracts with Managed Care Organizations (MCOs) to deliver the CHOICES waiver program to eligible beneficiaries.

• Tennessee Health Facilities Commission (HFC): The independent state agency that issues Certificates of Need and facility licenses (https://www.tn.gov/hfc.html).
• HFC Division of Licensure and Regulation: Conducts initial, renewal, and complaint surveys for home health agencies (https://www.tn.gov/hfc/division-of-licensure-and-regulation.html).
• Division of TennCare: Administers the state Medicaid program and oversees the CHOICES Long-Term Services and Supports waiver (https://www.tn.gov/tenncare.html).
• Centers for Medicare & Medicaid Services (CMS): Enforces federal Conditions of Participation for Medicare certification (https://www.cms.gov).
• TennCare Provider Registration Portal (PDMS): The centralized web-based system for Medicaid provider enrollment (https://pdms.tenncare.tn.gov).

3. Gatekeeping Prerequisites: Who Can Even Apply

Tennessee is a strict Certificate of Need (CON) state for home health agencies. You cannot submit a licensure application to the HFC without first obtaining an approved CON, which serves as a massive structural barrier to new entrants.

The CON process requires proving that the proposed service area (specific counties) lacks adequate home health access. This is highly contested by existing providers, and applications are frequently denied if incumbent agencies demonstrate they can absorb the patient volume.

• Certificate of Need (CON): Mandatory prior approval from the HFC demonstrating regional need before a licensure application can be accepted (https://www.tn.gov/hfc/certificate-of-need-information.html).
• Letter of Intent: Must be published in a local newspaper of general circulation in the proposed service area before filing the formal CON application.
• Business Entity Registration: The operating entity must be registered and in good standing with the Tennessee Secretary of State.
• National Provider Identifier (NPI): A Type 2 (Organizational) NPI is required prior to initiating Medicaid enrollment.
• Medicare Certification Intent: Agencies must typically prepare for Medicare certification (CMS 855A) concurrently with state licensure to participate in TennCare's network.

4. Licensure and Certification Requirements

Once the CON is secured, agencies apply for a Home Health Agency license through the HFC Division of Licensure and Regulation under Tenn. Code Ann. § 68-11-201. The agency must pass an initial state survey to receive its license.

To bill TennCare for skilled services, most agencies also seek Medicare certification via deemed status through an approved accrediting organization (ACHC, CHAP, or The Joint Commission), which substitutes for the state's Medicare certification survey.

• Licensure Application: Submit the HFC Initial Home Health Agency Application along with the required state fee, which is typically $810 or more.
• Statutory Authority: Agencies are regulated under Tenn. Code Ann. § 68-11-201 et seq. and HFC rules.
• Administrator Qualifications: Must designate a qualified administrator meeting Tennessee's specific educational and home care experience mandates.
• Policies and Procedures: Must develop a comprehensive manual covering patient rights, infection control, emergency preparedness, and clinical protocols.
• Medicare Certification (42 CFR Part 484): Required for agencies billing Medicare or Medicaid for skilled home health services.
• Accreditation: Deemed status surveys via ACHC, CHAP, or The Joint Commission are the standard pathway to achieve Medicare certification in Tennessee.

5. Medicaid Provider Enrollment

After obtaining state licensure and Medicare certification, providers must enroll in Tennessee Medicaid (TennCare) using the Provider Data Management System (PDMS).

Because TennCare operates under a managed care model, enrollment with the state is only the first step. Providers must subsequently secure contracts with the active Managed Care Organizations (MCOs) administering the CHOICES program to receive patient referrals and reimbursement.

• TennCare PDMS Portal: Submit the electronic enrollment application via the Provider Registration Portal (https://pdms.tenncare.tn.gov).
• CAQH ProView: Required for credentialing data synchronization for many practitioners and group practices in Tennessee.
• Application Fee: Payment of the federal Medicaid application fee, or proof of prior payment to Medicare or another state's Medicaid program.
• MCO Contracting: Must contract with TennCare MCOs (e.g., BlueCare Tennessee, UnitedHealthcare Community Plan, Wellpoint) to participate in the CHOICES waiver.
• Revalidation: TennCare requires provider revalidation every 3 to 5 years depending on the specific provider type and risk category.

6. Staffing, Training and Background Checks

Tennessee home health agencies must employ qualified clinical staff and ensure all personnel meet strict background and training requirements prior to patient contact.

Federal regulations mandate that home health aides complete a state-approved training program and competency evaluation, and clinical staff must hold active Tennessee licenses.

• Clinical Director: Must be a Registered Nurse (RN) with specific home health experience to oversee all clinical operations and staff.
• Background Checks: Mandatory fingerprint-based criminal background checks through the Tennessee Bureau of Investigation (TBI) for all patient-facing staff.
• Registry Verifications: Must check the Tennessee Department of Health Abuse Registry and the National Sex Offender Registry prior to hire.
• Home Health Aide Training: Aides must complete a minimum 75-hour training program and pass a competency evaluation per 42 CFR 484.36.
• In-Service Training: A minimum of 12 hours of annual in-service training is required for all home health aides.
• Professional Licensing: All nurses and therapists must hold active, unencumbered licenses verified through the Tennessee Department of Health.

7. Documentation, Policies and Records

Agencies must maintain rigorous clinical records and operational policies to comply with HFC licensure rules and Medicare Conditions of Participation.

The Plan of Care (CMS-485 or equivalent) is the central document for every patient, requiring a physician's signature and regular updates to justify the medical necessity of the services provided.

• Plan of Care (CMS-485): Must be established, signed by a physician, and reviewed/recertified at least every 60 days.
• OASIS Assessments: Mandatory completion and transmission of the Outcome and Assessment Information Set (OASIS) for all Medicare and Medicaid patients.
• Clinical Notes: Must be written the day service is rendered and incorporated into the clinical record within a strict timeframe.
• Emergency Preparedness: Comprehensive plan compliant with CMS Appendix Z, including risk assessments, communication plans, and annual drills.
• QAPI Program: Documented Quality Assessment and Performance Improvement program with measurable indicators and ongoing data collection.
• Record Retention: Clinical records must be retained for at least 5 years after the month the cost report to which the records apply is filed.

8. Billing, Rates and Claims

Home health billing in Tennessee is processed through the contracted TennCare MCOs for Medicaid patients, utilizing standard institutional claim formats.

Reimbursement rates for the CHOICES program are established by TennCare but administered by the MCOs, and skilled visits typically require prior authorization.

• Claim Format: Billed using the UB-04 (837I electronic format) for institutional home health claims.
• Prior Authorization: MCOs require prior authorization for home health episodes under the CHOICES waiver before services commence.
• EVV Compliance: Electronic Visit Verification (EVV) is required for personal care and home health aide services under the 21st Century Cures Act.
• Billing Codes: Standard HCPCS/CPT codes and revenue codes (e.g., 042X for physical therapy, 055X for skilled nursing).
• Payment Model: While Medicare uses the Patient-Driven Groupings Model (PDGM), TennCare MCOs may use fee-for-service or negotiated episodic rates.
• Timely Filing: Claims must typically be submitted within 120 days of the date of service, depending on the specific MCO contract terms.

9. Approval Sequence and Timeline

The pathway to becoming a billing home health agency in Tennessee is lengthy, primarily due to the CON process and Medicare certification timelines.

From the initial CON letter of intent to final MCO contracting, the entire process can take 12 to 18 months or more.

• Phase 1: Certificate of Need (CON) application, public notice, and HFC hearing (3-6 months).
• Phase 2: HFC Licensure Application submission and initial desk review of policies and procedures (30-60 days).
• Phase 3: Initial state licensure survey by HFC (scheduled after the agency is operational and ready).
• Phase 4: Medicare Certification/Deemed Status survey by an accrediting body (ACHC/CHAP) after treating a minimum number of patients (3-6 months).
• Phase 5: TennCare PDMS enrollment and Medicaid ID issuance (30-90 days).
• Phase 6: Credentialing and contracting with TennCare MCOs (90-120 days).

10. Common Denials and Survey Findings

HFC and accrediting bodies frequently cite agencies for failures in clinical documentation and infection control during initial and renewal surveys.

At the gatekeeping stage, CON applications are routinely denied if the applicant cannot definitively prove a lack of access in the target county, often due to fierce opposition from existing agencies.

• CON Denial: Failure to demonstrate unmet need or successful opposition by incumbent home health providers in the target county.
• Plan of Care Deficiencies: Missing physician signatures, delayed 60-day recertifications, or care provided outside the ordered scope.
• Incomplete Background Checks: Allowing staff to provide patient care before TBI fingerprint results and registry checks are fully cleared.
• OASIS Errors: Inaccurate coding or failure to transmit OASIS data to the state repository within the required 30-day window.
• Aide Supervision: Failure of the RN to conduct and document the required on-site supervisory visits for home health aides every 14 days.
• Application Expiration: HFC licensure applications expiring because the agency failed to become operational or pass survey within the allotted timeframe.

11. Key Contacts and Resources

Navigating Tennessee's home health landscape requires interaction with the Health Facilities Commission, TennCare, and federal oversight bodies.

Providers should regularly consult these official resources for rule updates, CON hearing schedules, and Medicaid provider bulletins.

• Tennessee Health Facilities Commission (HFC): https://www.tn.gov/hfc.html
• HFC Certificate of Need Program: https://www.tn.gov/hfc/certificate-of-need-information.html
• HFC Division of Licensure and Regulation: https://www.tn.gov/hfc/division-of-licensure-and-regulation.html
• TennCare Provider Registration Portal (PDMS): https://pdms.tenncare.tn.gov
• Division of TennCare (Medicaid): https://www.tn.gov/tenncare.html
• Tennessee Department of Health Abuse Registry: https://www.tn.gov/health/health-program-areas/health-professional-boards/registry.html

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