If you will be receiving payments made directly to you from TennCare for Medicare Cross-Over claims or you are participating in the EHR Incentive Payments Program, you must complete the Supplier Direct Deposit Authorization Instructions and TennCare ACH Supplemental Form. If you will be receiving payments from groups or entities you are associated with, ie; a Managed Care Organization, Dental Benefits Manager, etc., you do not need to complete the ACH forms. These forms are only needed if payment will be made to you directly by TennCare for Medicare Cross-Over claims or the EHR Incentive Program. If this applies to you, please utilize the links below to complete the necessary forms.

The ACH Enrollment Instructions for individual provider types link contains information on where to send your completed documents, a W-9 which can be found at the ACH Enrollment Instructions for Individual Provider Types link below and an ACH form to provide banking information. Once the forms are complete, send them to the address in the ACH Enrolment instructions for Individual Provider Types document link below.

If you have questions, please E-mail Provider.Registration@tn.gov