Tennessee - Skilled Nursing Services — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-08-16

In Tennessee, HCBS Skilled Nursing Services (RN and LPN care delivered in the home) for Medicaid populations are primarily administered through the TennCare CHOICES and Employment and Community First (ECF) CHOICES waiver programs. Because Tennessee does not offer a standalone "HCBS nursing" license, providers delivering these services must be licensed as a Home Care Organization Providing Home Health Services by the state.

The single biggest structural barrier to entry for this service in Tennessee is the Certificate of Need (CON) requirement. Before a prospective provider can even submit a licensure application to the state, they must successfully apply for and win a CON from the Health Facilities Commission, a highly competitive and expensive legal process requiring the applicant to prove that existing home health agencies in the target county are failing to meet patient demand.

1. Service Definition and Scope

In Tennessee, HCBS Skilled Nursing Services provide part-time or intermittent nursing care to members enrolled in TennCare CHOICES or ECF CHOICES who require professional medical assistance to remain safely in their homes. These services are strictly medical in nature and distinct from non-medical personal support services.

All skilled nursing services must be ordered by a physician, documented in the member's Person-Centered Support Plan (PCSP), and delivered by licensed clinicians operating within their state-defined scope of practice.

• Service Scope: Includes comprehensive nursing assessments, medication administration, tube feedings, wound care, catheter care, and other skilled treatments.
• Target Population: Adults with physical disabilities and seniors (CHOICES Groups 1, 2, and 3) and individuals with intellectual or developmental disabilities (ECF CHOICES).
• Provider Type: Must be a licensed Home Health Agency (HHA); Tennessee does not license independent nursing agencies for this waiver service outside of the HHA framework.
• Staffing: Services must be delivered by a Registered Nurse (RN) or a Licensed Practical Nurse (LPN) operating under the direct supervision of an RN.
• Authorization: Requires prior authorization from the member's Managed Care Organization (MCO) before any services can be rendered or billed.

2. Regulatory and Oversight Agencies

Oversight of skilled nursing providers in Tennessee is split between the facility licensing authority and the state Medicaid agency. Because TennCare operates entirely under a Section 1115 managed care waiver, day-to-day administration and credentialing are handled by three contracted Managed Care Organizations (MCOs).

Providers must maintain compliance with the rules of the licensing commission, the state Medicaid authority, and the specific MCOs they contract with.

• Tennessee Health Facilities Commission (HFC): Issues Certificates of Need, conducts surveys, and grants Home Health Agency licenses (https://www.tn.gov/hfc.html).
• Division of TennCare: The state Medicaid agency that manages the CHOICES programs and oversees provider enrollment (https://www.tn.gov/tenncare.html).
• TennCare Provider Registration Portal (PDMS): The mandatory state system for Medicaid ID issuance and taxonomy validation (https://pdms.tenncare.tn.gov/).
• Wellpoint Tennessee: A TennCare MCO responsible for network credentialing, authorizations, and claims (https://provider.wellpoint.com/tn/).
• BlueCare Tennessee: A TennCare MCO responsible for network credentialing, authorizations, and claims (https://bluecare.bcbst.com/).
• UnitedHealthcare Community Plan of Tennessee: A TennCare MCO responsible for network credentialing, authorizations, and claims (https://www.uhcprovider.com/en/health-plans-by-state/tennessee-health-plans/tn-comm-plan-home.html).

3. Gatekeeping Prerequisites: Who Can Even Apply

Tennessee heavily restricts the entry of new skilled nursing providers through a strict Certificate of Need (CON) process. This is a structural precondition; the state will reject any Home Health Agency licensure application that is not accompanied by an approved CON for the specific counties requested.

Even if a provider secures a CON and a license, they face a secondary gatekeeping barrier: MCO network adequacy. TennCare MCOs frequently close their networks to new home health providers if they determine they already have enough contracted agencies in a specific region.

• Certificate of Need (CON): Mandatory approval from the HFC required before establishing a new Home Health Agency or expanding an existing agency into new counties.
• Letter of Intent: A formal notice that must be published in a local newspaper and submitted to the HFC before a CON application can even be filed.
• CON Application Fee: A non-refundable fee starting at $3,000 and scaling upward based on projected capital costs.
• MCO Closed Networks: Wellpoint, BlueCare, and UHC may refuse to accept MLTSS Provider Enrollment Applications if their regional home health networks are deemed adequate.
• Medicare Certification Prerequisite: Many MCOs require home health agencies to achieve Medicare certification (Title XVIII) before they will allow them to credential for Medicaid HCBS contracts.

4. Licensure and Certification Requirements

To provide skilled nursing, the entity must be licensed as a Home Care Organization Providing Home Health Services by the HFC under Tenn. Comp. R. & Regs. 0720-27. This process verifies the agency's clinical competence, financial stability, and administrative structure.

The licensure process involves a detailed application, a substantial fee, and an initial state survey to verify compliance with clinical and administrative rules before the license is granted.

• Licensure Authority: Tennessee Health Facilities Commission (HFC) Division of Licensure and Regulation.
• Application Form: HFC Initial Licensure Application (PH-3506HHS).
• Licensure Fee: $1,404 initial application fee for Home Health Agencies.
• Insurance Minimums: Proof of General and Professional Liability Insurance (minimum $500,000 coverage) and Workers' Compensation.
• Administrator Qualifications: Must be a licensed physician, an RN, or an individual with at least one year of supervisory experience in home health care or a related health program.
• Initial Survey: Conducted by HFC surveyors to review policies, personnel files, and clinical records before the active license is issued.

5. Medicaid Provider Enrollment

Once licensed by the HFC, providers must register with TennCare to obtain a Medicaid ID. This is done exclusively through the TennCare Provider Registration Portal (PDMS) and is required before a provider can contract with any MCO.

Home health agencies are classified as High-Risk providers under federal ACA rules, which triggers enhanced screening requirements, including mandatory fingerprinting and application fees.

• Enrollment Portal: TennCare Provider Registration Portal (PDMS) (https://pdms.tenncare.tn.gov/).
• Risk Category: High-Risk, requiring an application fee (approximately $709) unless the fee has already been paid to Medicare for the current enrollment cycle.
• Taxonomy Matching: Specialty taxonomy codes entered in PDMS must perfectly match the provider's federal NPPES registry profile to avoid 90-day manual review holds.
• Required Documents: W-9, IRS Form 147C, HFC License, and NPI verification.
• MCO Contracting: A TennCare Medicaid ID does not guarantee payment; providers must separately complete the MLTSS Provider Enrollment Application for each MCO they wish to bill.

6. Staffing, Training and Background Checks

Tennessee requires strict credential verification and background screening for all clinicians entering a member's home. Agencies must ensure all nurses operate strictly within the Tennessee Nurse Practice Act.

Agencies must maintain a comprehensive staff development program and document all orientation and ongoing training in individual personnel files.

• Background Checks: Mandatory Tennessee Bureau of Investigation (TBI) fingerprint background sweeps for all patient-facing staff.
• Registry Checks: Mandatory pre-employment checks of the Tennessee Department of Health Abuse Registry and the National Sex Offender Registry.
• RN Qualifications: Active, unencumbered Registered Nurse license issued by the Tennessee Board of Nursing or a recognized compact state.
• LPN Supervision: LPNs must be supervised by an RN, with supervisory visits documented in the clinical record according to HFC and MCO frequency rules.
• CPR Certification: All nursing staff must maintain current, hands-on CPR/Basic Life Support certification.
• Orientation Training: Must cover TennCare CHOICES waiver rules, incident reporting, and abuse/neglect prevention before the clinician sees their first patient.

7. Documentation, Policies and Records

Clinical documentation must align with both HFC licensure standards and TennCare MCO requirements. The agency's internal plan of care must integrate seamlessly with the MCO's overarching Person-Centered Support Plan.

Agencies must maintain detailed administrative policies covering everything from emergency preparedness to patient rights and grievance procedures.

• Physician Orders: All skilled nursing services must be ordered by a physician and recertified at least every 60 days.
• Plan of Care: Must be individualized, integrated with the MCO's PCSP, and updated immediately as the patient's medical condition changes.
• Clinical Notes: Must be written, signed, and incorporated into the patient's permanent clinical record within 7 days of the service being provided.
• Emergency Preparedness: Must have a written plan complying with CMS and HFC standards for natural disasters, ensuring continuity of care for ventilator-dependent or high-acuity patients.
• Record Retention: Clinical records must be retained for a minimum of 10 years following the patient's discharge or death.

8. Billing, Rates and Claims

Because TennCare is a 100% managed care environment, providers do not bill the state directly for CHOICES services. Claims are submitted to the member's specific MCO using standard EDI formats.

Rates are negotiated directly with the MCOs, though they generally follow a state-established fee schedule baseline. Strict adherence to prior authorization and Electronic Visit Verification (EVV) is required for payment.

• Billing System: Claims are submitted via clearinghouse to the respective MCO's claims portal (Wellpoint, BlueCare, or UHC), not the state MMIS.
• Coding: Billed using standard HCPCS codes (e.g., G0299 for RN, G0300 for LPN) or specific waiver codes as defined in the individual MCO contract.
• Prior Authorization: 100% of CHOICES skilled nursing visits require prior authorization from the MCO; unapproved visits will result in total claim denial.
• Electronic Visit Verification (EVV): Mandatory for in-home services under the 21st Century Cures Act; providers must use the specific EVV vendor mandated by the MCO.
• Timely Filing: Typically 120 days from the date of service, but exact limits are dictated by the individual MCO contract and must be strictly monitored.

9. Approval Sequence and Timeline

Becoming a skilled nursing provider in Tennessee is a multi-year process due to the CON requirement. Providers must sequence their applications carefully, as each step is a prerequisite for the next.

Attempting to skip steps, such as applying for a Medicaid ID before the HFC license is in hand, will result in immediate rejection.

• Step 1: Certificate of Need (CON) application and approval from HFC (typically 4 to 6 months).
• Step 2: HFC Home Health Agency Licensure application and initial state survey (typically 3 to 6 months).
• Step 3: Medicare Certification survey, if required by MCOs for credentialing (typically 6 to 12 months).
• Step 4: TennCare Provider Registration Portal (PDMS) enrollment for Medicaid ID (typically 30 to 90 days).
• Step 5: MCO Credentialing and Contracting with Wellpoint, BlueCare, and UHC (typically 90 to 120 days per MCO).

10. Common Denials and Survey Findings

Applications and surveys frequently fail due to administrative errors, taxonomy mismatches, or failure to prove need during the CON process.

During HFC surveys, clinical documentation and RN supervision of LPNs are the most heavily scrutinized areas, often leading to citations or delayed licensure.

• CON Denial: Failing to definitively prove that existing agencies in the target county cannot meet the current patient demand.
• PDMS Rejection: Taxonomy codes entered in the TennCare portal not matching the provider's NPPES profile exactly, triggering indefinite manual review holds.
• Survey Deficiency: Failure to document RN supervisory visits for LPNs at the frequency required by state rule and MCO policy.
• Survey Deficiency: Incomplete personnel files, specifically missing TBI background checks or Abuse Registry verifications prior to the clinician's first shift.
• Credentialing Denial: Applying to an MCO that has declared a closed network for home health providers in that specific region.

11. Key Contacts and Resources

Use these official state and MCO resources to navigate the licensure, CON, and enrollment processes. Always verify current rules and fee schedules directly with the HFC and TennCare.

Because regulations and MCO network statuses frequently update, providers should establish direct contact with MCO network relations representatives early in the process.

• Tennessee Health Facilities Commission (HFC): Issues CONs and licenses (https://www.tn.gov/hfc.html).
• TennCare Provider Registration Portal (PDMS): Medicaid ID enrollment (https://pdms.tenncare.tn.gov/).
• TennCare CHOICES Program Info: Official waiver details (https://www.tn.gov/tenncare/long-term-services-supports/choices.html).
• Wellpoint Tennessee Provider Portal: MCO credentialing and resources (https://provider.wellpoint.com/tn/).
• BlueCare Tennessee Provider Portal: MCO credentialing and resources (https://bluecare.bcbst.com/).
• Tennessee Board of Nursing: License verification for RNs and LPNs (https://www.tn.gov/health/health-program-areas/health-professional-boards/nursing-board.html).

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