Tennessee TennCare home care margin recovery.
You delivered the visits.
In Tennessee, TennCare LTSS runs through the MCOs, EVV funnels through CareBridge, and timely filing is set in each MCO contract rather than by state rule, so Reeve does not state a single Tennessee window. Reeve reads your own billing export, right in your browser, and shows you the authorized, delivered, billed, and paid columns side by side, so the gaps have a record attached.
Every dollar of personal care in Tennessee passes through four states of being, and they do not always agree.
The payer approved a number of units. In Tennessee that is TennCare long-term services delivered through the member's MCO, BlueCare, Amerigroup or Wellpoint, or UnitedHealthcare, under CHOICES for LTSS and ECF CHOICES for members with I/DD. Personal care, personal assistance, attendant care, and respite are authorized by the MCO for the member. The clock and the ceiling both live here.
The people who deliver the care worked the visit and it landed in Electronic Visit Verification. Tennessee runs all EVV through CareBridge, the state aggregator, which passes verified visits through to the MCOs. The visit becomes an accepted CareBridge transaction, or it does not, and the claim has to reconcile through CareBridge to the MCO.
A claim went out to the member's MCO with a Medicaid ID, date of service, NPI, a HCPCS code, and a unit count. Personal assistance and personal care ride on T1019, attendant care on S5125 per 15 minutes, and respite on S5150. Units are counted in quarter hours on the 15-minute lines, so small miscounts add up fast.
The claim matched, cleared its other edits, and remitted from the MCO. Or it hit a mismatch and denied.
The leaks live in the gaps between those four columns, and Tennessee has two rules that turn a gap into lost money: EVV visits have to reconcile through CareBridge to the correct MCO on member, code, and units, and timely filing is written into each MCO contract rather than into state rule, so the window that applies to a line depends on which plan holds the member.
- 01Delivered but never billed
- 02CareBridge visit not passed through to the correct MCO
- 03Code mismatch between T1019, S5125, and S5150
- 04Billed fewer units than the visit shows
- 05Aged out of the filing window the member's MCO contract sets
Every number is illustrative and synthetic. Because your own export may not carry a rate for every code, findings on this page are expressed in hours, units, and records to check against your own rate sheet, never in dollars Reeve made up.
19 claims paid clean this quarter where the accepted CareBridge visit shows more delivered quarter-hour units than the claim billed. Example: a visit accepted for 11 units of S5125, claim billed 10. The claim matched and paid, so nothing flagged, but 1 units per visit across 19 visits is 19 units of delivered care that never turned into a claim line. Records attached, ready to check against your contracted rate.
11 claim lines where T1019 was billed on a member authorized for S5125 attendant care, or the reverse. The MCO matches code to authorization, so the miscoded lines denied. Reeve names the MCO on each line and sorts by date of service so you can read them against the window in that plan's contract.
3 clients where delivered and accepted CareBridge units exceed the authorized MCO units on file under CHOICES or ECF CHOICES. This is not recoverable, and Reeve will not pretend it is. It surfaces separately as over-delivery, care your aides gave that was never authorized, so you can see the exposure and fix the MCO authorization going forward rather than quote it as money owed.
22 delivered-and-accepted CareBridge visits with no matching claim found in the export, sorted by date of service and oldest first, with the MCO of record named on each. Tennessee sets timely filing by contract, so Reeve ranks these by age instead of declaring which are gone.
5 visits where the CareBridge record is accepted but did not pass through cleanly to the correct MCO for the member, most often because of an MCO-of-record change or a member-eligibility gap. Each one is a denial waiting to happen or one that already did, with the specific visit and claim record paired so your biller can see exactly which field to correct.
Why an annual audit or the EMR alone misses this.
A once-a-year audit looks back over twelve months. In Tennessee every MCO contract carries its own filing window, and they are short. By the time an annual review names a denied line, the window has been shut for most of the year and the reason is lost.
The EMR is not built to catch it either. Your EMR knows what it billed and which MCO it went to. CareBridge knows what visit was accepted and passed through. The MCO remittance knows what paid. Those three live in three places, and the mismatch is in the seam between them. A clean match shows green in your billing screen even when the visit carried more units than the claim, or when the MCO of record changed mid-month.
The gap only shows when you put the accepted CareBridge transaction, the MCO of record, the claim with its code, and the remittance in the same view and read them together, oldest first. That is the one thing Reeve does. It reads across the seam.
That is what Reeve reads for in Tennessee: what CareBridge accepted, what the authorization allowed, what you billed, and what actually paid, read side by side rather than audited for rate.
Plain answers, on the record.
Straight answers on how the Tennessee Margin Review works, what it touches, and what it will not claim.
Collect is money you never captured. Cover is money a payer can still take back.
Reeve reports the two separately and never adds them together, because only one of them is yours to go and get. The Margin Review reads both on your own export and costs nothing.
One pass over your own export, in your browser. The findings are yours to keep, with no obligation.
The recovery lane. Care you delivered and never billed, units short of what was authorized, lines paid under the published rate.
Everything in Collect, plus the exposure lane. Retired codes, authorizations at the end of their period, care delivered past what was approved.
Month to month, no annual contract. Read-only in every tier. Run the free review.
Try it yourself. Run a free Margin Review.
No sales call. No account to create. Export your data, open the review in your browser, and see your authorized, delivered, billed, and paid columns lined up in about the time it takes to read this page.
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Read-only. Reeve reads your export and does not write to your EMR, does not file a claim, does not move money.
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Names coded locally. Names and member identifiers are replaced with a coded reference in your browser before any analysis runs.
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Your file is processed in your browser, and no name is written into any output. No upload of identified data, no server holding your client list.
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Yours to keep. The findings are yours whether or not we ever work together.
Reeve reads your billing read-only and replaces its names with coded references before any math runs. Every example figure is illustrative and synthetic, method rather than results, and Reeve makes no guarantee of recovery.