TNGA is a provider network company focused on contracting with independent therapy providers (PT/OT/ST) in order to arrange for outpatient rehabilitative services on behalf of health plans and their assigned members. TNGA and its affiliated companies provide rehabilitation services to over 1.2 million health plan members through its 1,100+ contracted provider locations. TNGA and its affiliated companies operate in four different U.S. markets and cover all lines of business (Medicaid, SCHIP, Medicare, Commercial HMO, Commercial PPO).
TNGA is a privately owned organization. Its owners are also the founders and operators of the company. For more than seven years, TNGA and its affiliated companies have contracted with nine different health plans to provide therapy network management services.
TNGA is contracted with WellCare of Georgia to coordinate the provision of outpatient therapy (PT/OT/ST) services to WellCare members through a network of therapy providers contracted with TNGA. The company has been in partnership with WellCare Health Plans, Inc. for over six years, providing therapy management for WellCare’s Florida lines of business.
TNGA maintains regular business hours of 8 a.m. to 5 p.m. Monday–Friday. After regular business hours, a TNGA representative is available for urgent cases that need immediate attention by calling 1-855-825-7818, Option #1.
The holidays that TNGA observes are: New Year’s Day, Memorial Day, Independence Day, Labor Day, Thanksgiving, the day after Thanksgiving and Christmas Day.
TNGA will be administering therapy benefits for all WellCare of Georgia’s Medicaid, PeachCare for Kids®, and Medicare members. TNGA’s claims payment turnaround standards are as follows: Medicare—95 % of clean electronic claims are paid within 15 calendar days from the date of receipt and 95 % of clean paper claims are paid within 30 calendar days of receipt. Medicaid: 95% of clean electronic claims are processed in 15 business days and 95 % of clean paper claims are paid within 30 calendar days of receipt. For additional information, please visit www.mytnga.com.
Yes, TNGA will be processing provider claims for the therapy services under its agreement with WellCare of Georgia.
A number of factors were taken into consideration as part of the methodology for determining the case rate level and pricing for each therapy case. These factors include:
- Diagnosis code(s) as determined by the referring physician
- Medical guidelines promulgated by CMS, WellCare and Apollo guidelines
- Consultation with different actively practicing physiatrists and therapists regarding appropriate case level assignments
- The member’s compliance with attending therapy sessions
- Other (if any) medical conditions and/or medical care provided to the member
- Any previous rehab that was provided to the member for the same medical condition
- The historical utilization patterns and data from several hundred various therapy providers that have been contracted with the network for up to eight years and that have been servicing over 1 million covered lives
Members Enrolled in Babies Can’t Wait
- Reimbursement for therapy services provided to a child enrolled in the Babies Can’t Wait Program will be paid fee for service.
- If providing therapy to a child enrolled in the Babies Can’t Wait Program, the provider must submit the Individualized Family Service Plan (IFSP), which must indicate that the child is enrolled in Babies Can’t Wait.
- For more information regarding the Babies Can’t Wait Program, please contact your TNGA Provider Relations Representative at 855-825-7818.
Each authorized case rate is valid for a certain defined period.
During this time period and after already providing an appropriate amount of therapy services, a provider may request an “upgrade” from TNGA in order to receive a higher-than-normal payment level for that specific member. Please note that upgrades should only be requested for the limited number of therapy cases where more therapy is required than what would otherwise be expected for the medical condition being treated. Upgrade requests do not require the therapist to obtain an additional referral/authorization from a primary care or specialty physician.
Also, after the initial authorized course of treatment has elapsed and it is determined that additional therapy is medically necessary, the member can receive another referral/authorization for therapy services by a primary or specialty physician. Should the member require additional therapy under this circumstance, a new case rate will be assigned by the network to the treating therapist.
It is important to note that the number of therapy visits performed by a therapist under TNGA’s case rate model is not restricted or specifically defined. The treating therapist makes the medical determination as to the appropriate plan of care that each member may require, based on his/her particular medical condition.
If the child has not met the intended goals at the conclusion of the case period, does TNGA recoup part or the entire case rate?
No, there is not a financial recoupment of the case rate under these circumstances.
A separate case rate is paid for each medically necessary therapy discipline (PT, OT, ST). The network reimburses for therapy services in the same manner whether it is performed on an individual member basis or through group therapy sessions.
All non-hospital providers may submit authorization requests via fax to 855-825-7820. Providers are also able to submit information to the TNGA through TNGA’s web portal. Providers may access the web portal by logging into www.mytnga.com. For questions concerning the web portal or to request a provider web portal account, please send us an email and include your contact name, TIN, provider contact name, provider contact email and provider contact phone number.
Hospital providers must use the state of Georgia DCH secure provider portal (GAMMIS) as the single point of entry for submission of prior authorization requests for Georgia Medicaid members. However, hospital providers may verify the status of their Intake request on the TNGA provider web portal.
Submitting patient information by regular email is not allowed because of PHI.
Clinical support can be requested by contacting TNGA at 855-825-7818 and a clinician, in turn, will contact the provider and schedule a time/date to speak that is convenient for both individuals.
When can I expect to receive the case rate payment to be disbursed – at the beginning of the therapy period or at the conclusion?
The case rate is processed upon receipt of the first claim associated with the case. Clean claims are paid on a weekly basis and most are paid within 15 business days when electronically submitted, 30 days for paper claims. Providers should continue to submit subsequent claims for services rendered in relationship to the case period, although no additional payment will be disbursed. Reimbursement to providers for therapy services rendered to members enrolled in Babies Can’t Wait will be paid fee for service. Clean claims are paid on a weekly basis and most are paid within 15 business days when electronically submitted, 30 days for paper claims.