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MTM in Medicaid – Act NOW to Enroll!

MTM in Medicaid Pilot Program
Revised April 2, 2020

Pharmacists: Take Steps NOW to Enroll and Participate in the MTM in Medicaid Pilot Program

As reported to members in May 2017, the Tennessee Pharmacists Association (TPA) worked with members of the Tennessee General Assembly, TennCare, and managed care organizations to introduce and pass Public Chapter 363, requiring the creation of the Pharmacist-Provided Medication Therapy Management (MTM) in Medicaid Pilot Program. The State of Tennessee has now published a webpage dedicated to the MTM in Medicaid Pilot Program. The Tennessee MTM in Medicaid Pilot Program, which has been recognized nationally as an innovative model for increasing patient access to pharmacist-provided care and incorporating pharmacists into Medicaid programs as medical providers, began on January 1, 2018.

TPA Needs to Hear from Member Pharmacists TODAY:

TPA is currently compiling a list of member pharmacists who are interested in participating in this Pilot Program. If you would like to participate in the MTM in Medicaid Pilot Program, please email MTMpilot@tnpharm.org, indicating your willingness to participate. TennCare will determine pharmacists’ eligibility for participation in the Pilot Program based on numerous factors, including provider location and completion of the required steps below. If you have specific questions about TennCare’s selection process, email TennCare directly at TennCare.MTMpilot@tn.gov.

Tell TPA You're Interested!Pilot Program – Pharmacist Qualifications:

The MTM in Medicaid Pilot Program authorizes qualified Tennessee-licensed pharmacists, working under collaborative practice agreements with prescribers, to provide MTM services to eligible high-risk TennCare patients enrolled in their Patient Centered Medical Homes and Tennessee Health Link organizations. Community pharmacists, health-system pharmacists, long-term care pharmacists, and others may participate.

TennCare Patient Eligibility for Pharmacist-Provided MTM Services:

Patients with multiple chronic illnesses and multiple medications who are enrolled in either a TennCare Patient Centered Medical Home (PCMH Wave 1 or PCMH Wave 2) or Tennessee HealthLink Organization:

  Medium-High, High, and Critical Risk Patients Identified Through Risk Stratification

  • Chronic Illness and Disability Payment System and Pharmacy Payment System (CDPS + Rx) risk adjustment model assesses risk by combining diagnosis and pharmacy-based information (http://cdps.ucsd.edu/)

Patients With Targeted Disease States

  • Pediatric Asthma
  • Pediatric DM

MTM in Medicaid: Reimbursement Methodology

Service Description Modifier Code Case Rate Payment Limits Units
Targeted Disease States (Juvenile Asthma and Diabetes)  U1 $55.00  2 Months  1 unit for each
case rate
Medium-High Risk  U2 $55.00  3 Months  1 unit for each
case rate
Critical, High Risk U3 $75.00 6 Months 1 unit for each
case rate
Exceptions (Requires
appropriate approval)
U4 Rate based on level of care modifier Limit based on appropriate approval 1 unit for each
case rate
CPT Code CPT Code Description
99605 Medication therapy management service(s) provided by pharmacist, individual, face-to-face with patient, with assessment and intervention if provided; new patient visit, initial 15 minutes
99606 Medication therapy management service(s) provided by pharmacist, individual, face-to-face with patient, with assessment and intervention if provided; established patient visit, initial 15 minutes
99607 Add-on code for each additional 15-minute increment
98966 Telephone assessment and management services provided by a qualified non-physician health care professional to an established patient. 5-10 minutes
98967 Telephone assessment and management services provided by a qualified non-physician health care professional to an established patient. 11-20 minutes
98968 Telephone assessment and management services provided by a qualified non-physician health care professional to an established patient. 21-30 minutes

CLICK HERE for additional information about MTM in Medicaid Reimbursement Methodology. Click here for Collaborative Pharmacy Practice Resource Page
Specific Steps Member Pharmacists Should Take to Participate in the Pilot Program:

Steps 1-5 below can be completed now, however, not all entities listed in Step 6 have their enrollment procedures in place. This should be resolved shortly, and TPA will update members at that time. You should then be able to complete Step 6 relatively quickly.   TennCare will determine pharmacists’ eligibility for participation based on numerous factors. If you have specific questions about TennCare’s selection process, email TennCare directly at TennCare.MTMpilot@tn.gov.
  1. Obtain a National Provider Identifier (NPI) Number as an “Individual” and “Pharmacist”
    • Use the designation “183500000X – Pharmacist”
  2. Enroll as a TennCare Pharmacist Medical Provider
    • If you need assistance with the required forms, please contact TennCare Provider Services at Provider.Registration@tn.gov or 1-800-852-2683.
  3. Begin the CAQH Credentialing Process
    • CLICK HERE for a guide to completing the CAQH credentialing process.
  4. Contact the TennCare Patient Centered Medical Homes (PCMH Wave 1 and PCMH Wave 2) and Tennessee Health Link Organizations in your area to in your area to formalize collaborative pharmacy practice agreements for the delivery of MTM services to TennCare beneficiaries served by these organizations. Agreements should incorporate the full scope of pharmacists’ expertise and skills in the provision of Medication Therapy Management services.
  5. Authorize the use of the TennCare Care Coordination Tool (CCT) administered through Altruista Health by completing the TennCare Acceptable Use Policy and Registered Authorization Requests for your CCT administrator.
    • If you are part of an approved PCMH, please email the TennCare MTM Pilot Network Team (TennCare.Pharmacy.AdobeSign@tn.gov) for possible manual registration.
    • The Care Coordination Tool landing page can be accessed HERE. Users can log into the tool using the user name and password provided by Altruista.
    • If you have already received your user name and password and are having trouble using the Care Coordination Tool or have questions, contact the Altruista (CCT) Support Help Desk at support@altruistahealth.com or 855-596-2491.
  6. Register on the CAQH EnrollHub for the networks listed below. You will need to contact the three TennCare Managed Care Organizations (MCO’s) below and specifically request to be enrolled as a medical provider for the TennCare MTM in Medicaid Pilot Program. The MCO’s are working to finalize their enrollment procedures. TPA will provide updates as they become available. The provider manuals for the three TennCare Managed Care Organizations administering the Pilot Program are linked below:

TPA will continue to work with TennCare to identify and collect contact information for pharmacists wishing to participate in the MTM in Medicaid Pilot Program and will provide updates to members as more details become available.