Out of Network providers who are not in our system and have provided services to a TLC Member should complete and submit the appropriate forms to us for processing.

Are you a Facility or Individual Provider? Please click here for instructions regarding the disclosure forms.  Please click on the appropriate links below to download the appropriate forms:

Facility	Individual Provider
Out of Network Provider Loading Form Facility Disclosure Form  W-9	Out of Network Provider Loading Form Individual Practitioner Disclosure Form W-9

Providers must submit all claims for medical services within 120 days of the date of service, or for inpatient services, within 120 days from the date of discharge. However, in the case of retroactive TLC eligibility determinations, 120 days is allowed from created date that is supplied by the Bureau of TennCare tape updates.

              Example: Eligibility for 04/15/2004, TennCare
              tape updated on 02/12/2004, eligibility retro 120
              days from date TLC created the update to the
              received date of the claim.

TLC will not be obligated to pay claims filed after the expiration of the applicable time period. The TLC Enrollees are not responsible for charges filed after the 120-day filing period. If TLC is secondary to a commercial insurer or Medicare, claims must be submitted within 120 days from the date the primary insurer’s remittance was produced.