Tenn. Comp. R. & Regs. 1200-11-03-.05 - AUTHORIZATION AND REIMBURSEMENTS

(1) The program shall authorize only those services for reimbursement that relate to the child's eligible diagnosis(es). The Program shall be a payor of last resort, paying for covered services only after exhaustion of the family's other payor sources, except for applicable deductibles, co-insurance, and/or co-payment. The program shall not pay the difference between the billed amount for a service and the amount paid by a third party payor based upon a contractual agreement. Except as provided in 1200-11-03-.05(5), the program shall only authorize reimbursement for services for children currently enrolled in the program.
(2) Reimbursement.
(a) The program shall authorize reimbursement for services as follows:
1. Inpatient hospitalization and rehabilitation services shall be based on a per diem rate as negotiated between the Program and the facility.
2. Drug reimbursements shall be based upon the Department's average wholesale price. The shipping and handling fee may be reimbursed according to the program's most current Delegated Authority (DA).
3. Services for which there is a Medicare fee shall be at least the equivalent of the prior year's Medicare fee schedule for Tennessee multiplied by 75%. The program shall update the required minimum reimbursement rate on a biennial basis, but at its discretion, the program may at other times update the reimbursement rate to account for significant changes in fees. The updated National Conversion Factor is referenced in the Federal Register on or about October 31 each year.
4. Therapies, medical supplies, durable medical equipment, prosthetics, orthotics, and orthodontic/dental treatment services shall be based on the American Medical Association Physicians' Current Procedural Terminology (CPT) codes relative value units and determined by the State of Tennessee purchasing procedures and the Delegated Purchase Authority for the program.
5. Nutritional supplements, hearing aids, and hearing aid supplies shall be determined by the State of Tennessee purchasing procedures and the Delegated Purchasing Authority for the Program.
6. Non-hospital services for which there is no Medicare fee shall be paid at least 75% of the average of three (3) bids, one from each grand division of the state.
(b) The program shall not authorize reimbursement for any covered service provided over twelve (12) months prior to the receipt of the request for reimbursement.
(3) The program shall determine authorization of providers and vendors for reimbursement in accordance with the standards as designated in these rules and determined by the Department of Health and the Department of Finance and Administration.
(4) The Department shall determine billing procedures for hospitals, institutions, facilities, agencies, providers, vendors, or distinct parts thereof rendering services.
(5) Upon receipt of a determination from the assigned provider that a requested service is urgent and medically necessary, the State CSS Program Director may grant authorization prior to exhaustion of resources from third party payors, provided however, that the grant or denial of such authorization shall be final.


Tenn. Comp. R. & Regs. 1200-11-03-.05
Original rule filed April 12, 1979; effective May 28, 1979. Repeal and new rule filed December 30, 1983; effective January 29, 1984. Amendment filed May 29, 1990; effective July 13, 1990. Repeal and new rule filed March 21, 2000; effective July 28, 2000. Repeal and new rule filed October 9, 2002; effective December 23, 2002. Repeal and new rules filed September 6, 2016; effective 12/5/2016.

Authority: T.C.A. §§ 4-5-202, 68-1-103, 68-12-101 et seq., 42 U.S.C. § 701(a), 42 U.S.C. § 704(b)(1), and 42 U.S.C. § 706(a)(2).

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