Tennessee - Skilled Respite Service — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-08-16

In Tennessee, Skilled Respite is an essential Home and Community-Based Service (HCBS) provided under the TennCare CHOICES and Employment and Community First (ECF) CHOICES waiver programs. It delivers short-term relief to primary caregivers of members with complex medical needs, utilizing licensed nursing staff (RNs or LPNs) when the member's acuity exceeds the scope of a non-medical caregiver.

The single biggest structural barrier to entry for this service in Tennessee is the Certificate of Need (CON) requirement. Tennessee does not have a standalone "skilled respite" license; therefore, agencies providing in-home nursing must be licensed as a Home Care Organization - Home Health Agency. Securing a CON from the Health Facilities Commission requires proving a quantitative need for new home health services in a specific county, which routinely blocks new applicants before a licensure application can even be filed.

1. Service Definition and Scope

Skilled Respite in Tennessee provides temporary, substitute nursing care for TennCare members living in community settings. It is specifically authorized for individuals whose Person-Centered Support Plan (PCSP) dictates that their medical fragility requires a licensed nurse for safe monitoring and intervention during the primary caregiver's absence.

Because this service involves skilled nursing tasks such as ventilator management, complex wound care, or intravenous medication administration, it cannot be performed by standard Personal Support Services Agencies (PSSAs). It must be delivered by a licensed Home Health Agency.

• Target Population: TennCare CHOICES and ECF CHOICES members with complex medical needs requiring nursing-level care.
• Service Setting: Delivered in the member's primary residence or community setting, not in a facility.
• Scope of Practice: Includes medication administration, tube feeding, tracheostomy care, and ventilator monitoring.
• Duration Limits: TennCare CHOICES generally caps in-home respite at 216 hours or 9 days per calendar year.
• Licensure Category: Must operate under a Home Care Organization - Home Health Agency license.
• Exclusions: Cannot be used for routine childcare, nor can it be billed concurrently with standard continuous home health nursing.

2. Regulatory and Oversight Agencies

Oversight of Skilled Respite in Tennessee is divided between facility regulators and Medicaid authorities. The Health Facilities Commission handles the legal authority to operate, while the Department of Disability and Aging (DDA) and TennCare manage waiver compliance.

Because TennCare operates entirely through a managed care model, providers must also answer directly to the Managed Care Organizations (MCOs) that authorize and pay for the services.

• Health Facilities Commission (HFC): Administers the Certificate of Need program and issues Home Health Agency licenses (https://www.tn.gov/hfc.html).
• Division of TennCare: The state Medicaid authority governing the CHOICES and ECF CHOICES programs (https://www.tn.gov/tenncare.html).
• Department of Disability and Aging (DDA): Oversees HCBS provider credentialing, quality monitoring, and incident management (https://www.tn.gov/disability-and-aging.html).
• BlueCare Tennessee: TennCare Managed Care Organization responsible for network contracting and claims (https://bluecare.bcbst.com).
• UnitedHealthcare Community Plan: TennCare Managed Care Organization responsible for network contracting and claims (https://www.uhccommunityplan.com/tn).
• Wellpoint: TennCare Managed Care Organization responsible for network contracting and claims (https://www.wellpoint.com/tn/medicaid).

3. Gatekeeping Prerequisites: Who Can Even Apply

Tennessee enforces severe structural preconditions for skilled nursing providers. The absolute hardest barrier is the Certificate of Need (CON). You cannot submit a Home Health Agency license application without first winning a CON, which requires proving that existing county agencies cannot meet the population's needs.

Furthermore, TennCare is a 100% managed care state. Even with a license and state Medicaid enrollment, you cannot bill for services unless you successfully secure a network contract with at least one of the three TennCare MCOs, which frequently utilize closed networks for HCBS.

• Certificate of Need (CON): Mandatory approval from the HFC required before a Home Health Agency license application is accepted; strictly limits market entry by county.
• MCO Network Contracting: Must secure a contract with BlueCare, UHC, or Wellpoint; MCOs may declare their networks closed to new home health providers at any time.
• DDA Credentialing: Must pass the DDA Provider Credentialing process to be recognized as an HCBS waiver provider before MCOs will execute a contract.
• Business Registration: Must be registered and in good standing with the Tennessee Secretary of State.
• Physical Location: Must maintain a physical office within Tennessee or a border county that meets HFC zoning and operational standards.

4. Licensure and Certification Requirements

To provide Skilled Respite, an agency must obtain a Home Care Organization - Home Health Agency license from the Health Facilities Commission. This process involves a detailed application, fee submission, and a rigorous initial state survey.

The agency must demonstrate compliance with state health regulations regarding clinical supervision, patient rights, and emergency preparedness before the license is granted.

• Licensure Rule: Governed by Tenn. Comp. R. & Regs. 1200-08-26 (Standards for Home Care Organizations Providing Home Health Services).
• Application Form: Must submit HFC Form PH-2961 (Application for License as a Health Care Facility).
• Licensure Fee: The initial and annual renewal fee for a Home Health Agency is typically $1,404.
• Insurance Minimums: Must maintain at least $1 million in professional liability insurance and statutory workers' compensation coverage.
• Clinical Leadership: Must employ a qualified agency administrator and a supervising Registered Nurse (RN) available during all operating hours.
• Initial Survey: Must pass an on-site HFC health and safety inspection prior to license issuance.

5. Medicaid Provider Enrollment

Medicaid enrollment in Tennessee is a dual process. Providers first register with the state via the TennCare Provider Registration Portal (PDMS) to obtain a Medicaid ID. However, this state-level enrollment only grants billing rights in theory.

To actually receive authorizations and payments, the provider must subsequently complete credentialing with the individual MCOs using CAQH ProView.

• State Portal: Enrollment is processed through the TennCare Provider Registration Portal (PDMS) (https://pdms.tenncare.tn.gov).
• NPI Requirement: The agency must obtain and register a Type 2 (Organizational) National Provider Identifier.
• Application Fee: Subject to the federal ACA institutional provider application fee (approximately $731) unless waived via concurrent Medicare enrollment.
• CAQH ProView: Must maintain an updated profile in CAQH ProView for MCO credentialing data extraction (https://proview.caqh.org).
• EFT/ERA Setup: Must establish Electronic Funds Transfer and Electronic Remittance Advice directly with the contracted MCOs.
• Revalidation: State Medicaid enrollment must be revalidated every 5 years through the PDMS portal.

6. Staffing, Training and Background Checks

Skilled Respite must be delivered by licensed nurses. Tennessee strictly regulates the background screening and credentialing of all healthcare personnel entering a Medicaid member's home.

Agencies must ensure that all LPNs operate under the direct supervision of an RN, and all staff must clear multiple state and federal registries before their first shift.

• Nursing Qualifications: Staff must hold an active, unencumbered RN or LPN license issued by the Tennessee Board of Nursing.
• LPN Supervision: LPNs must have documented clinical supervision by an RN, including periodic on-site supervisory visits.
• Criminal Background Checks: Mandatory fingerprint-based state and federal background checks processed through the Tennessee Bureau of Investigation (https://www.tn.gov/tbi.html).
• Registry Screenings: Must check the Tennessee Department of Health Abuse Registry, National Sex Offender Registry, and OIG List of Excluded Individuals/Entities (LEIE) prior to hire and monthly.
• CPR Certification: All direct care nursing staff must maintain active, hands-on CPR and First Aid certification.
• HCBS Training: Staff must complete DDA-mandated training on person-centered practices, incident reporting, and HCBS settings rules.

7. Documentation, Policies and Records

Providers must maintain comprehensive clinical and administrative records that satisfy both HFC home health regulations and TennCare HCBS waiver requirements.

Documentation must clearly justify the skilled nature of the respite visit and prove that the services delivered matched the MCO Care Coordinator's authorization.

• Person-Centered Support Plan (PCSP): Services must strictly align with the goals and hours authorized in the member's MCO-approved PCSP.
• Clinical Notes: Nurses must document shift start/stop times, specific skilled interventions performed, and the patient's clinical status for every visit.
• Electronic Visit Verification (EVV): Must utilize the state-mandated EVV system to capture the exact time and location of the respite shift.
• Incident Reporting: Critical incidents (e.g., falls, medication errors) must be reported to the MCO and DDA via the Reportable Event Management System within 24 hours.
• Emergency Plans: Must maintain individualized emergency preparedness plans for each member, detailing backup staffing protocols.
• Record Retention: All clinical, EVV, and billing records must be securely retained for a minimum of 5 years.

8. Billing, Rates and Claims

In Tennessee's managed care system, providers do not bill the state directly. Claims are submitted to the specific MCO (BlueCare, UHC, or Wellpoint) that covers the member.

Skilled Respite requires strict adherence to prior authorizations, and claims will automatically deny if they are not supported by validated Electronic Visit Verification (EVV) data.

• Billing Portals: Claims are submitted via MCO-specific clearinghouses (e.g., Availity for Wellpoint/BlueCare, UHC Provider Portal).
• HCPCS Codes: Typically billed using T1005 (Respite care services, 15 minutes) appended with skilled nursing modifiers (TD for RN, TE for LPN).
• Prior Authorization: 100% of skilled respite hours must be prior-authorized by the MCO Care Coordinator before the shift occurs.
• EVV Integration: Claims are systematically matched against EVV punch data; missing or mismatched EVV data results in immediate claim denial.
• Rate Structure: TennCare establishes maximum allowable HCBS rates, but final reimbursement is dictated by the provider's specific MCO contract.
• Timely Filing: Claims must generally be submitted within 120 days of the date of service, depending on the MCO contract terms.

9. Approval Sequence and Timeline

Becoming a Skilled Respite provider in Tennessee is a protracted process, primarily due to the Certificate of Need requirement. The entire sequence from initial CON filing to final MCO contracting typically takes 12 to 18 months.

Providers cannot begin the Medicaid enrollment or MCO contracting phases until the HFC has fully issued the Home Health Agency license.

• Step 1: Submit Letter of Intent and CON Application to the HFC; await hearing and approval (3-6 months).
• Step 2: Submit Form PH-2961 for Home Health Agency licensure to the HFC (2-3 months).
• Step 3: Undergo and pass the initial HFC on-site health and safety survey (1-2 months).
• Step 4: Register in the TennCare PDMS portal and complete DDA HCBS credentialing (1-2 months).
• Step 5: Apply for network inclusion and complete credentialing with BlueCare, UHC, and/or Wellpoint (2-4 months).
• Step 6: Complete MCO-specific EVV and billing system training before accepting the first authorization.

10. Common Denials and Survey Findings

Applicants frequently fail at the very first step by having their Certificate of Need denied due to an inability to prove a lack of existing home health capacity in their target county.

For operational providers, HFC surveyors and MCO auditors routinely issue citations or recoup funds for documentation lapses, particularly regarding EVV compliance and nursing supervision.

• CON Denial: Application rejected by HFC because existing county home health agencies are deemed sufficient to meet population needs.
• EVV Mismatches: Claims denied by MCOs because the nurse's GPS clock-in location did not match the member's authorized home address.
• Lapsed Supervision: HFC citations for failing to document the required RN supervisory visits for LPNs providing in-home care.
• Registry Check Failures: Citations for allowing a nurse to begin orientation or direct care before the Tennessee Abuse Registry check was fully completed.
• Unauthorized Overtime: Claim denials for billing respite hours that exceeded the member's 216-hour annual CHOICES cap.
• Missing Clinical Justification: Recoupments during MCO audits because nursing notes did not describe skilled interventions, making the care look like non-medical sitting.

11. Key Contacts and Resources

Navigating Tennessee's skilled respite requirements requires coordinating with facility regulators, Medicaid authorities, and managed care plans. Use these official resources to access applications, portals, and policy manuals.

Always verify current CON schedules and MCO network status before investing capital into a new agency application.

• Health Facilities Commission (CON & Licensure): https://www.tn.gov/hfc.html
• TennCare Provider Registration Portal (PDMS): https://pdms.tenncare.tn.gov
• Department of Disability and Aging (DDA) Provider Info: https://www.tn.gov/disability-and-aging/provider-information.html
• Tennessee Bureau of Investigation (Background Checks): https://www.tn.gov/tbi.html
• BlueCare Tennessee Provider Portal: https://bluecare.bcbst.com/providers
• UnitedHealthcare Community Plan TN: https://www.uhccommunityplan.com/tn
• Wellpoint Tennessee Medicaid: https://www.wellpoint.com/tn/medicaid

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