Tenn. Comp. R. & Regs. 1200-13-14-.01 - DEFINITIONS
(1) ABUSE shall mean enrollee practices, or
enrollee involvement in practices, including overutilization, waste or
fraudulent use/misuse of a TennCare Program that results in cost or utilization
which is not medically necessary or medically justified. Abuse of a TennCare
Pharmacy Program justifies placement on lock-in or prior approval status for
all enrollees involved. Activities or practices which may evidence abuse of the
TennCare Pharmacy Program include, but are not limited to, the following:
forging or altering drug prescriptions, selling TennCare paid prescription
drugs, failure to control pharmacy overutilization activity while on lock-in
status and visiting multiple prescribers or pharmacies to obtain prescriptions
that are not medically necessary.
(2) ACCESS TO HEALTH INSURANCE shall mean the
opportunity an individual has to obtain group health insurance as defined
elsewhere in these rules. If a person could have enrolled in work-related or
other group health insurance during an employer's or group's open enrollment
period and chose not to enroll (or had the choice made for him by a family
member) that person shall not be considered to lack access to insurance upon
closure of the open enrollment period. Neither the cost of an insurance policy
or health plan nor the fact that an insurance policy is not as comprehensive as
that of the TennCare Program shall be considered in determining eligibility to
enroll in any TennCare category where being uninsured is an eligibility
prerequisite.
(3) ADVERSE BENEFIT
DETERMINATION shall mean, but is not limited to, a delay , denial, reduction,
suspension or termination of TennCare benefits . See
42 C.F.R. §
438.400.
(4) AGGREGATE COST-SHARING CAP. The maximum
amount a family may pay out-of-pocket for TennCare covered services during a
calendar quarter (January 1 through March 31, April 1 through June 30, July 1
through September 30, October 1 through December 31). Amounts paid for
non-covered services , including payments for services that exceed a benefit
limit, are not counted in the aggregate cost-sharing cap. Amounts paid by the
family for third party insurance are not counted in the aggregate cost-sharing
cap.
(5) APPLICATION PERIOD shall
mean a specific period of time determined by the Bureau of TennCare during
which the Bureau will accept applications for the TennCare Standard Spend Down
category as described in the Bureau's rules at
1200-13-14-.02.
(6) BENEFITS shall mean the health care
package of services developed by the Bureau of TennCare and which define the
covered services available to TennCare enrollees. Additional benefits are
available through the TennCare CHOICES program, as described in Rule 1
20013-01-.05, and the ECF CHOICES program, as described in Rule
1200-13-01-.31. CHOICES benefits
are available only to persons who qualify for and are enrolled in the CHOICES
program. ECF CHOICES benefits are available only to persons who qualify for and
are enrolled in the ECF CHOICES program.
(7) BUPRENORPHINE ENHANCED SUPPORTIVE
MEDICATION-ASSISTED RECOVERY AND TREATMENT ("BESMART"). A treatment model
comprised of comprehensive treatment and recovery related supports for adult
(21 and older) enrollees with opioid use disorder (OUD)
("participants").
(8) BUREAU OF
TENNCARE (BUREAU) shall mean the administrative unit of TennCare which is
responsible for the administration of TennCare as defined elsewhere in these
rules.
(9) CALL-IN LINE shall mean
the toll-free telephone line used as the single point of entry during an open
application period to accept new applications for the Standard Spend Down
Program.
(10) CAPITATION PAYMENT
shall mean the fee which is paid by the State to a managed care contractor
operating under a risk-based contract for each enrollee covered by the plan for
the provision of medical services, whether or not the enrollee utilizes
services or without regard to the amount of services utilized during the
payment period.
(11) CAPITATION
RATE shall mean the amount established by the State for the purpose of
providing payment to participating managed care contractors operating under a
risk-based contract.
(12) CARETAKER
RELATIVE shall mean that individual as defined at Tennessee Code Annotated §
71-3-103.
(13) CATEGORICALLY NEEDY shall mean that
category of TennCare Medicaid-eligibles as defined at
1240-03-02-.02
of the rules of the Tennessee Department of Human Services - Division of
Medical Services.
(14) CHOICES. See
"TennCare CHOICES in Long-Term Care ."
(15) CHOICES 1 and 2 Carryover Group. See
definition in Rule
1200-13-01-.02.
(16) CHOICES At-Risk Demonstration Group. See
definition in Rule
1200-13-01-.02.
(17) CHOICES 217-Like Group. See definition
in Rule 1200-13-01-.02.
(18) CHOICES Group 1. See definition in Rule
1200-13-01-.02.
(19) CHOICES Group 2. See definition in Rule
1200-13-01-.02.
(20) CMS (CENTERS FOR MEDICARE AND MEDICAID
SERVICES) (formerly known as HCFA) shall mean the agency within the United
States Department of Health and Human Services that is responsible for
administering Title XVIII, Title XIX, and Title XXI of the Social Security
Act.
(21) COBRA shall mean health
insurance coverage provided pursuant to the Consolidated Omnibus Budget
Reconciliation Act.
(22) CODE OF
FEDERAL REGULATIONS (C.F.R.) shall mean Federal regulations promulgated to
explain specific requirements of Federal law .
(23) COMMENCEMENT OF SERVICES shall mean the
time at which the first covered service(s) is/are rendered to a TennCare member
for each individual medical condition.
(24) COMMISSIONER shall mean the chief
administrative officer of the Tennessee Department where the TennCare Bureau is
administratively located, or the Commissioner 's designee.
(25) COMPLETED APPLICATION is an application
where:
(a) All required fields have been
completed;
(b) It is signed and
dated by the applicant or the applicant's parent or guardian;
(c) It includes all supporting documentation
required by the TDHS or the Bureau to deter mine TennCare eligibility,
technical and financial requirements as set out in these rules; and
(d) It includes all supporting documentation
required to prove TennCare Standard medical eligibility as set out in these
rules.
(26) CONTINUATION
OR REINSTATEMENT OF BENEFITS (COB) shall mean the circumstances under which an
enrollee may keep receiving, or, in the case of reinstatement, get back and
keep receiving, the benefit under appeal until the appeal is resolved. See
42 C.F.R. §§
431.230,
431.231 and
438.420.
(27) CONTINUOUS ENROLLMENT shall refer to the
ability of certain individuals determined eligible for the TennCare Program to
enroll at any time during the year. Continuous enrollment is limited to persons
in the following two groups:
(b) Individuals who are losing their
Medicaid , who are uninsured, who are under nineteen (19) years of age, and who
meet the qualification for TennCare Standard as "Medicaid Rollovers," in
accordance with the provisions of Rule
1200-13-14-.02.
(28) CONTRACT PROVIDER shall have
the same meaning as Participating Provider .
(29) CONTRACTOR shall mean an organization
approved by the Tennessee Department of Finance and Administration to provide
TennCare-covered benefits to eligible enrollees in the TennCare Medicaid and
TennCare Standard programs.
(30)
CONTRACTOR RISK AGREEMENT (CRA) shall mean the document delineating the terms
of the agreement entered into by the Bureau of TennCare and the Managed Care
Contractors.
(31) CONTROLLED
SUBSTANCE. A drug, substance, or immediate precursor identified by the U.S.
Department of Justice, Drug Enforcement Administration or by the Tennessee Drug
Control Act as having the potential for abuse and the likelihood of physical or
psychological dependence if used incorrectly.
(32) COPAY. A fixed fee that is charged to
certain TennCare enrollees for certain TennCare services.
(33) CORE MEDICAID POPULATION shall mean
individuals eligible under Title XIX of the Social Security Act,
42 U.S.C. §§
1396, et seq., with the exception of the
following groups: individuals receiving SSI benefits as determined by the
Social Security Administration; individuals eligible under a Refugee status;
individuals eligible for emergency services as an illegal or undocumented
alien; individuals receiving interim Medicaid benefits with a pending Medicaid
disability determination; individuals with forty-five (45) days of presumptive
eligibility; and children in DCS custody.
(34) COST-EFFECTIVE ALTERNATIVE SERVICE shall
mean a service that is not a covered service but that is approved by TennCare
and CMS and provided at an MCC's discretion. TennCare enrollees are not
entitled to receive these services. Cost-effective alternative services may be
provided because they are either (1) alternatives to covered Medicaid services
that, in the MCC's judgment, are cost-effective or (2) preventative in nature
and offered to avoid the development of conditions that, in the MCC's judgment,
would require more costly treatment in the future. Cost-effective alternative
services need not be determined medically necessary except to the extent that
they are provided as an alternative to covered Medicaid services. Even if
medically necessary, cost effective alternative services are not covered
services and are provided only at an MCC's discretion.
(35) COST SHARING shall mean the amounts that
certain enrollees in TennCare are required to pay for their TennCare coverage
and covered services. Cost sharing includes copayments.
(36) COVERED SERVICES shall mean the services
and benefits that:
(a) TennCare contracted
MCCs cover, as set out elsewhere in this Chapter and in Rule
1200-13-01-.05; or
(b) In the instance of enrollees who are
eligible for and enrolled in federal Medicaid waivers under Section 1915(c) of
the Social Security Act, the services and benefits that are covered under the
terms and conditions of such waivers.
(37) CPT4 CODES are descriptive terms
contained in the Physician's Current Procedural Terminology, used to identify
medical services and procedures performed by physicians or other licensed
health professionals.
(38) DBM
(DENTAL BENEFITS MANAGER) shall mean a contractor approved by the Tennessee
Department of Finance and Administration to provide dental benefits to
enrollees in the TennCare Program to the extent such services are covered by
TennCare.
(39) DEDUCTIBLE. A
specified amount of money paid each year by an insured person for benefits
before his health plan starts paying claims.
(40) DELAY shall mean any failure to provide
timely receipt of TennCare services, and no specific waiting period may be
required before the enrollee can appeal.
(41) DEMAND LETTER shall mean a letter sent
by TennCare to a TennCare Standard enrollee with premium obligations notifying
the enrollee that he is at least 60 days delinquent in his premium
payments.
(42) DISCONTINUED
DEMONSTRATION GROUP shall mean the group of non-Medicaid eligible individuals
who were enrolled in TennCare Standard on April 29, 2005, when the categories
in which they were enrolled were terminated, and who have not yet been enrolled
in TennCare Medicaid or disenrolled from the TennCare program.
(43) DISENROLLMENT shall mean the
discontinuance of an individual's enrollment in TennCare.
(44) DURABLE MEDICAL EQUIPMENT (DME) shall
mean equipment that can withstand repeated use, can be removable, is primarily
and customarily used to serve a medical purpose, generally is not useful to a
person in the absence of an illness or injury, is suitable for use in any
non-institutional setting in which everyday life activities take place, and is
related to the patient's physical disorder. Non-institutional settings do not
include a hospital or nursing facility (NF). Routine DME items, including but
not limited to wheelchairs (except as defined below), walkers, hospital beds,
canes, commodes, traction equipment , suction machines, patient lifts, weight
scales, and other items provided to a member receiving services in a NF that
are within the scope of per diem reimbursement for NF services shall not be
covered or reimbursable under the Medicaid program separate and apart from
payment for the NF service. Customized wheelchairs, wheelchair seating systems,
and other items that are beyond the scope of Medicaid reimbursement for NF
services shall be covered by the member's managed care organization, so long as
such items:
(a) Are medically necessary for
the continuous care of a member ; and
(b) Must be custom-made or modified or may be
commercially available , but must be individually measured and selected to
address the member's unique and permanent medical need for positioning, support
or mobility; and
(c) Are solely for
the use of that member and not for other NF residents.
(45) EARLY AND PERIODIC SCREENING, DIAGNOSIS,
AND TREATMENT (EPSDT) Services, a covered benefit for TennCare
Medicaid -enrolled children only, shall mean:
(a) Screening in accordance with professional
standards, and interperiodic, diagnostic services to determine the existence of
physical or mental illnesses or conditions of TennCare Medicaid enrollees under
age twenty-one (21); and
(b) Health
care, treatment, and other measures, described in
42 U.S.C. §
1396a(a) to correct or
ameliorate any defects and physical and mental illnesses and conditions
discovered.
(46)
ELIGIBLE shall mean a person who has been determined to meet the eligibility
criteria of TennCare Medicaid or TennCare Standard.
(47) EMPLOYMENT AND COMMUNITY FIRST (ECF)
CHOICES shall mean the program defined in Rule
1200-13-01-.02 and described in
Rule 1200-13-01-.31.
(48) ENROLLEE shall mean an individual
eligible for and enrolled in the TennCare program or in any Tennessee federal
Medicaid waiver program approved by the Secretary of the U.S. Department of
Health and Human Services pursuant to Sections 1115 or 1915 of the Social
Security Act. As concerns MCC compliance with these rules, the term only
applies to those individuals for whom the MCC has received at least one day's
prior written or electronic notice from the TennCare Bureau of the individual's
assignment to the MCC.
(49)
ENROLLMENT shall mean the process by which a TennCare-eligible person becomes
enrolled in TennCare.
(50) ESCORT
shall mean an individual who accompanies an enrollee to receive a medically
necessary service. For the purpose of determining whether an individual may
qualify as an escort who may be transported without cost to the enrollee as a
covered TennCare benefit, the following criteria apply:
(a) Any person over the age of twelve (12)
selected by the enrollee;
(b) Any
person under the age of twelve (12) is presumed to be too young to serve as an
escort. At the time of request for transportation, this presumption can be
overcome by specific facts provided by the enrollee, which would demonstrate to
a reasonable person that the proposed escort could in fact be of assistance to
the enrollee; and
(c) Any person
under the age of six (6) is excluded in all cases from the role of
escort.
(51) FAMILY
shall mean that as defined in the rules of the Tennessee Department of Human
Services found at 1240-01-03 and 1240-01-04, Family Assistance Division, and
1240-03-03, Division of Medical Services.
(52) FEDERAL FINANCIAL PARTICIPATION (FFP)
shall mean the Federal Government's share of a state's expenditure under the
Title XIX Medicaid Program.
(53)
FINAL AGENCY ACTION shall mean the resolution of an appeal by the TennCare
Bureau or an initial decision on the merits of an appeal by an administrative
judge or hearing officer when such initial decision is not modified or
overturned by the TennCare Bureau. Final agency action shall be treated as
binding for purposes of these rules.
(54) FRAUD shall mean an intentional
deception or misrepresentation made by a person who knows or should have known
that the deception could result in some unauthorized benefit to himself or some
other person . It includes any act that constitutes fraud under applicable
federal or state law .
(55) GRAND
DIVISIONS shall mean the three (3) distinct geographic areas of the State of
Tennessee, known as Eastern, Middle, and Western, as designated in Tennessee
Code Annotated §
4-1-201.
(56) GROUP HEALTH INSURANCE shall mean an
employee welfare benefit plan to the extent that the plan provides medical care
to employees or their dependents (as defined under the terms of the plan)
directly through insurance reimbursement mechanism. This definition includes
those types of health insurance found in the Health Insurance Portability And
Accountability Act of 1996, as amended, definition of creditable coverage (with
the exception that the 50 or more participants criteria does not apply), which
includes Medicare and TRICARE. Health insurance benefits obtained through COBRA
are included in this definition. It also covers group health insurance
available to an individual through membership in a professional organization or
a school.
(57) HANDICAPPING
MALOCCLUSION shall mean a malocclusion which causes one of the following
medical conditions:
(a) A nutritional
deficiency that has proven non-responsive to medical treatment without
orthodontic treatment. The nutritional deficiency must have been diagnosed by a
qualified treating physician and must have been documented in the qualified
treating physician 's progress notes. The progress notes that document the
nutritional deficiency must predate the treating orthodontist's prior
authorization request for orthodontics.
(b) A speech pathology that has proven
non-responsive to speech therapy without orthodontic treatment. The speech
pathology must have been diagnosed by a qualified speech therapist and must
have been documented in the qualified speech therapist's progress notes. The
progress notes that document the speech pathology must predate the treating
orthodontist's prior authorization request for orthodontics.
(c) Laceration of soft tissue caused by a
deep impinging overbite. Occasional cheek biting does not constitute laceration
of soft tissue. Laceration of the soft tissue must be documented in the
treating orthodontist's progress notes and must predate the treating
orthodontist's prior authorization request for orthodontics.
Anecdotal information is insufficient to document the
presence of a
(58) HEALTH INSURANCE, for the purposes of
determining eligibility under these regulations:
(a) Shall mean:
1. Any hospital and medical expense-incurred
policy;
2. Medicare ;
3. TRICARE;
4. COBRA ;
5. Medicaid ;
6. State health risk pool;
7. Nonprofit health care service plan
contract;
8. Health maintenance
organization subscriber contracts;
9. An employee welfare benefit plan to the
extent that the plan provides medical care to an employee or his/her dependents
(as defined under the terms of the plan) directly through insurance, any form
of self insurance, or a reimbursement mechanism;
10. Coverage available to an individual
through membership in a professional organization or a school;
11. Coverage under a policy covering one
person or all the members of a family under a single policy where the contract
exists solely between the individual and the insurance company;
12. Any of the above types of policies where:
(i) The policy contains a type of benefit
(such as mental health benefits ) which has been completely exhausted;
(ii) The policy contains a type of benefit
(such as pharmacy) for which an annual limitation has been reached;
(iii) The policy has a specific exclusion or
rider of non-coverage based on a specific prior existing condition or an
existing condition or treatment of such a condition; or
13. Any of the types of policies listed above
will be considered health insurance even if one or more of the following
circumstances exists:
(i) The policy contains
fewer benefits than TennCare;
(ii)
The policy costs more than TennCare; or
(iii) The policy is one the individual could
have bought during a specified period of time (such as COBRA ) but chose not to
do so.
(b)
Shall not mean:
1. Short-term
coverage;
2. Accident
coverage;
3. Fixed indemnity
insurance;
4. Long-term care
insurance;
5. Disability income
contracts;
6. Limited benefits
policies as defined elsewhere in these rules;
7. Credit insurance;
8. School-sponsored sports-related injury
coverage;
9. Coverage issued as a
supplemental to liability insurance;
10. Automobile medical payment
insurance;
11. Insurance under
which benefits are payable with or without regard to fault and which are
statutorily required to be contained in any liability insurance policy or
equivalent self-insurance;
12. A
medical care program of the Indian Health Services (IHS) or a tribal
organization;
13. Benefits received
through the Veteran's Administration; or
14. Health care provided through a government
clinic or program such as, but not limited to, vaccinations, flu shots,
mammograms, and care or services received through a disease- or
condition-specific program such as, but not limited to, the Ryan White Care
Act.
(59)
HEALTH MAINTENANCE ORGANIZATION (HMO) shall mean an entity licensed by the
Tennessee Department of Commerce and Insurance under applicable provisions of
Tennessee Code Annotated (T.C.A.) Title 56, Chapter 32 to provide health care
services.
(60) HEALTH PLAN shall
mean a Managed Care Organization authorized by the Tennessee Department of
Finance and Administration to provide medical and behavioral services to
enrollees in the TennCare Program.
(61) HEARING OFFICER shall mean an
administrative judge or hearing officer who is not an employee , agent or
representative of the MCC or who did not participate in, nor was consulted
about, any TennCare Bureau review prior to the State Fair Hearing
(SFH).
(62) HIPAA shall mean the
Health Insurance Portability and Accountability Act of 1996, as
amended.
(63) HOME HEALTH SERVICES
shall mean:
(a) Any of the services identified
in
42 C.F.R. §
440.70 and delivered in accordance with the
provisions of
42 C.F.R. §
440.70. "Part-time or intermittent nursing
services" and "home health aide services" are covered only as defined
specifically in these rules.
1. Part-time or
intermittent nursing services.
(i) To be
considered "part-time or intermittent," nursing services must be provided as no
more than one visit per day, with each visit lasting less than eight (8) hours,
and no more than 27 total hours of nursing care may be provided per week. In
addition, nursing services and home health aide services combined must total
less than or equal to eight (8) hours per day and 35 or fewer hours per week.
On a case-by-case basis, the weekly total for nursing services may be increased
to 30 hours and the weekly total for nursing services and home health aide
services combined may be increased to 40 hours for patients qualifying for
Level 2 skilled nursing care.
(ii)
Part-time or intermittent nursing services are not covered if the only skilled
nursing function needed is administration of medications on a p.r.n. (as
needed) basis. Nursing services may include medication administration; however,
a nursing visit will not be extended in order to administer medication or
perform other skilled nursing functions at more than one point during the day,
unless skilled nursing services are medically necessary throughout the
intervening period. If there is more than one person in the household who is
determined to require TennCare-reimbursed home health nursing services, it is
not necessary to have multiple nurses providing the services. A single nurse
may provide services to multiple enrollees in the same home and during the same
hours, as long as he can provide these services safely and appropriately to
each enrollee.
(iii) The above
limits may be exceeded when medically necessary for children under the age of
21.
2. Home health aide
services.
(i) Home health aide services must
be provided as no more than two visits per day with care provided less than or
equal to eight (8) hours per day. Nursing services and home health aide
services combined must total less than or equal to eight (8) hours per day and
35 or fewer hours per week. On a case-by-case basis, the weekly total may be
increased to 40 hours for patients qualifying for Level 2 skilled nursing care.
If there is more than one person in a household who is determined to require
TennCare-reimbursed home health aide services, it is not necessary to have
multiple home health aides providing the services. A single home health aide
may provide services to multiple enrollees in the same home and during the same
hours, as long as he can provide these services safely and appropriately to
each enrollee.
(ii) The above
limits may be exceeded when medically necessary for children under the age of
21.
(b) Home
health providers shall only provide services to the recipient that have been
ordered by the treating physician and are pursuant to a plan of care and shall
not provide other services such as general child care services, cleaning
services, preparation of meals, or services to other household members. Because
children typically have nonmedical care needs which must be met, to the extent
that home health services are provided to a person under 18 years of age, a
responsible adult (other than the home health care provider) must be present at
all times in the home during the provision of home health services unless all
of the following criteria are met:
1. The
child is non-ambulatory; and
2. The
child has no or extremely limited ability to interact with caregivers;
and
3. The child shall not
reasonably be expected to have needs that fall outside the scope of medically
necessary TennCare covered benefits (e.g. the child has no need for general
supervision or meal preparation) during the time the home health provider is
present in the home without the presence of another responsible adult;
and
4. No other children requiring
adult care or supervision shall be present in the home during the time the home
health provider is present in the home without the presence of another
responsible adult, unless these children meet all the criteria stated above and
are also receiving TennCare-reimbursed home health services.
(64) INCOME shall mean
that definition of income in rule 1240-01-04 of the Tennessee Department of
Human Services - Family Assistance Division.
(65) INDIVIDUAL HEALTH INSURANCE shall mean
health insurance coverage under a policy covering one person or all the members
of a family under a single policy where the contract exists solely between that
person and the insurance company.
(66) INITIATING PROVIDER shall mean the
provider who renders the first covered service to a TennCare member whose
current medical condition requires the services of more than one (1)
provider.
(67) INMATE shall mean an
individual confined in a local, state, or federal prison, jail, youth
development center, or other penal or correctional facility, including a
furlough from such facility.
(68)
IN-NETWORK PROVIDER shall have the same meaning as Participating
Provider .
(69) INPATIENT
REHABILITATION FACILITIES shall mean rehabilitation hospitals and distinct
parts of hospitals that are designated as 'IRFs' by Medicare.
(70) INSTITUTION FOR MENTAL DISEASES (IMD)
shall mean a hospital, nursing facility, or other institution of more than 16
beds that is primarily engaged in providing diagnosis, treatment, or care of
persons with mental diseases, including medical attention, nursing care, and
related services.
(71) LICENSED
MENTAL HEALTH PROFESSIONAL shall mean a Board eligible or a Board certified
psychiatrist or a person with at least a Master's degree and/or clinical
training in an accepted mental health field which includes, but is not limited
to, counseling, nursing, occupational therapy, psychology, social work,
vocational rehabilitation, or activity therapy with a current valid license by
the Tennessee Licensing Board for the Healing Arts.
(72) LIMITED BENEFITS POLICY shall mean a
policy of health coverage for a specific disease (e.g., cancer), or an accident
occurring while engaged in a specified activity (e.g., schoolbased sports), or
which provides for a cash benefit payable directly to the insured in the event
of an accident or hospitalization (e.g., hospital indemnity).
(73) LOCK-IN PROVIDER . A provider , pharmacy
or physician , chosen by an enrollee on pharmacy lock-in status to whom the
enrollee is assigned by TennCare for the purpose of receiving covered pharmacy
services.
(74) LOCK-IN STATUS. The
restriction of an enrollee to a specified physician, or to a specified pharmacy
provider at a specified single location.
(75) LONG-TERM CARE shall mean programs and
services described under Rule 1200-13-01.01.
(76) MCC (MANAGED CARE CONTRACTOR ) shall
mean:
(a) A Managed Care Organization,
Pharmacy Benefits Manager and/or a Dental Benefits Manager which has signed a
TennCare Contractor Risk Agreement with the State and operates a provider
network and provides covered health services to TennCare enrollees;
or
(b) A Pharmacy Benefits Manager,
Behavioral Health Organization or Dental Benefits Manager which subcontracts
with a Managed Care Organization to provide services; or
(c) A State government agency that contracts
with TennCare for the provision of services.
(77) MCO (Managed Care Organization) shall
mean an appropriately licensed Health Maintenance Organization (HMO) approved
by the Bureau of TennCare as capable of providing medical, behavioral, and
long-term care services in the TennCare Program.
(78) MEDICAID shall mean the federal- and
state-financed, state-run program of medical assistance pursuant to Title XIX
of the Social Security Act. Medicaid eligibility in Tennessee is determined by
the Tennessee Department of Human Services, under contract to the Tennessee
Department of Finance and Administration. Tennessee residents determined
eligible for SSI benefits by the Social Security Administration are also
enrolled in Tennessee's TennCare Medicaid program.
(79) MEDICAID "ROLLOVER" ENROLLEE shall mean
a TennCare Medicaid enrollee who no longer meets technical eligibility
requirements for Medicaid and will be afforded an opportunity to enroll in
TennCare Standard in accordance with the provisions of these rules.
(80) MEDICAL ASSISTANCE shall mean health
care, services and supplies furnished to an enrollee and funded in whole or in
part under Title XIX of the Social Security Act,
42 U.S.C. §§
1396, et seq. and Tennessee Code Annotated §§
71-5-101,
et seq. Medical assistance includes the payment of the cost of care, services,
drugs and supplies. Such care, services, drugs, and supplies shall include
services of qualified providers who have contracted with an MCC or are
otherwise authorized to provide services to TennCare enrollees (i.e., emergency
services provided out-of-network or medically necessary services obtained
out-of-network because of an MCC's failure to provide adequate access to
services in-network).
(81) MEDICAL
RECORD shall mean all medical histories; records, reports and summaries;
diagnoses; prognoses; records of treatment and medication ordered and given;
x-ray and radiology interpretations; physical therapy charts and notes; lab
reports; other individualized medical documentation in written or electronic
format; and analyses of such information.
(82) MEDICAL SUPPLIES shall mean covered
medical supplies that are deemed medically necessary and appropriate and are
prescribed for use in the diagnosis and treatment of medical conditions.
Medically necessary medical supplies not included as part of institutional
services shall be covered only when provided by or through a licensed home
health agency, by or through a licensed medical vendor supplier or by or
through a licensed pharmacist.
(83)
MEDICALLY ELIGIBLE shall mean a person who has met the medical eligibility
criteria for the TennCare Standard program through a mechanism permitted under
the provisions of these rules.
(84)
MEDICALLY NECESSARY is defined by Tennessee Code Annotated, Section
71-5-144,
and shall describe a medical item or service that meets the criteria set forth
in that statute. The term "medically necessary," as defined by Tennessee Code
Annotated, Section
71-5-144,
applies to TennCare enrollees. Implementation of the term "medically necessary"
is provided for in these rules, consistent with the statutory provisions, which
control in case of ambiguity. No enrollee shall be entitled to receive and
TennCare shall not be required to pay for any items or services that fail fully
to satisfy all criteria of "medically necessary" items or services, as defined
either in the statute or in the Medical Necessity rule chapter at
1200-13-16.
(85) MEDICALLY NEEDY
shall mean that category of TennCare Medicaid -eligibles as defined in rule
1240-03-02-.03
of the Tennessee Department of Human Services - Division of Medical
Services.
(86) MEDICARE shall mean
the program administered through the Social Security Administration pursuant to
Title XVIII, available to most individuals upon attaining age sixty-five (65),
to some disabled individuals under age sixty-five (65), and to individuals
having End Stage Renal Disease (ESRD).
(87) MEMBER shall mean a TennCare Medicaid -
or TennCare Standard-eligible individual who is enrolled in a managed care
organization.
(88) NON-CONTRACT
PROVIDER shall have the same meaning as Non-Participating Provider .
(89) NON-PARTICIPATING PROVIDER shall mean a
TennCare provider, as defined in this Rule, who is not contracted with a
particular enrollee 's MCO. This term may include TennCare providers who furnish
services outside the managed care program on a fee-for-service basis, as well
as TennCare providers who receive Medicare crossover payments from
TennCare.
(90) NON-TENNCARE
PROVIDER shall mean a provider who is not enrolled in TennCare and who accepts
no TennCare reimbursement for any service, including Medicare crossover
payments.
(91) OPEN ENROLLMENT
shall mean a designated period of time, determined by the Bureau of TennCare,
during which persons who are not currently TennCare eligible may apply for the
Standard Spend Down program.
(92)
OPEN MEDICAID CATEGORIES shall mean those Medicaid eligibility categories for
which enrollment has not been closed pursuant to authority granted by CMS as
part of the TennCare demonstration project.
(93) OUT-OF-NETWORK PROVIDER shall have the
same meaning as Non-Participating Provider .
(94) OUT-OF-STATE EMERGENCY PROVIDER shall
mean a provider outside the State of Tennessee who does not participate in
TennCare in any way except to bill for emergency services, as defined in this
Chapter, provided out-of-state to a particular MCC's enrollee . An Out-of-State
Emergency Provider must abide by all TennCare rules and regulations, including
those concerning provider billing of enrollees as found in Rule
1200-13-14-.08. In order to
receive payment from TennCare , Out-of-State Emergency Providers must be
appropriately licensed in the state in which the emergency services were
delivered, they must enroll with TennCare and they must not be excluded from
participation in Medicare or Medicaid .
(95) OVERUTILIZATION shall mean any of the
following:
(a) The enrollee initiated use of
TennCare services or supplies at a frequency or amount that is not medically
necessary or medically justified.
(b) Overutilization , or attempted
overutilization , of the TennCare Pharmacy Program which justifies placement on
lock-in status for all enrollees involved.
(c) Activities or practices which may
evidence overutilization of the TennCare Pharmacy Program including, but not
limited to, the following:
1. Treatment by
several physicians for the same diagnosis;
2. Obtaining the same or similar controlled
substances from several physicians;
3. Obtaining controlled substances in excess
of the maximum recommended dose;
4.
Receiving combinations of drugs which act synergistically or belong to the same
class;
5. Frequent treatment for
diagnoses which are highly susceptible to abuse ;
6. Receiving services and/or drugs from
numerous providers;
7. Obtaining
the same or similar drugs on the same day or at frequent intervals;
or
8. Frequent use of the emergency
room in non-emergency situations in order to obtain prescription
drugs.
(96)
PACE Carryover Group. See definition in Rule
1200-13-01-.02.
(97) PARTICIPATING PROVIDER shall mean a
TennCare provider, as defined in this Rule, who has entered into a contract
with an enrollee 's Managed Care Contractor .
(98) PBM (PHARMACY BENEFITS MANAGER) shall
mean an organization approved by the Tennessee Department of Finance and
Administration to administer pharmacy benefits to enrollees to the extent such
services are covered by the TennCare Program. A PBM may have a signed TennCare
Contractor Risk Agreement with the State, or may be a subcontractor to an
MCO.
(99) PERSONAL CARE SERVICES
shall refer to an optional Medicaid benefit defined at
42 C.F.R. §
440.167 that, per the Tennessee Medicaid
State Plan, Tennessee has not elected to include in the TennCare benefit
package. To the extent that such services are available to children under the
age of 21 when medically necessary under the provisions of EPSDT, the Bureau of
TennCare designates home health aides as the providers qualified to deliver
such services. When medically necessary, personal care services may be
authorized outside of the home setting when normal life activities temporarily
take the recipient outside of that setting. Normal life activity for a child
under the age of 21 means routine work (including work in supported or
sheltered work settings); licensed child care; school and school-related
activities; religious services and related activities; and outpatient health
care services (including services delivered through a TennCare home and
community based services waiver program). The home health aide providing
personal care services may accompany the recipient but may not drive. Normal
life activities do not include non-routine or extended home absences.
(100) PHYSICIAN shall mean a person licensed
pursuant to chapter 6 or 9 of title 63 of the Tennessee Code
Annotated.
(101) POVERTY LEVEL
shall mean the poverty level established by the Federal Government.
(102) POWER SEATING ACCESSORIES. Accessories
available to modify a power wheelchair base are covered by TennCare when all
listed criteria are met as follows:
(a) Power
Seat Elevation System.
1. It is ordered by
the Enrollee 's treating physician.
2. An assessment conducted by a licensed
physical therapist or licensed occupational therapist establishes that:
(i) The Enrollee has the cognitive ability
and enough upper extremity function to carry out mobility-related activities of
daily living such as feeding, grooming, dressing, and transferring;
and
(ii) The activities for which
the accessory will be used are conducted primarily in the enrollee 's
home.
(b)
Power Standing System.
1. It is ordered by the
Enrollee 's treating physician.
2.
An assessment conducted by a licensed physical therapist or licensed
occupational therapist establishes that the Enrollee :
(i) Has a chronic condition that causes him
to have limited or no ability to stand; and
(ii) Has a physical condition that allows him
to stand, when supported, for meaningful periods of time, i.e., he will not
suffer loss of blood pressure or have problems with bowel or urine retention;
and
(iii) Has the cognitive ability
and enough upper extremity function to carry out mobility-related activities of
daily living such as feeding, grooming, dressing, and transferring;
and
(iv) Meets at least one other
complex rehabilitation criterion for a power seat accessory such as a tilt seat
and also qualifies for a Group 3 base Power Wheelchair.
(103) POWER WHEELCHAIR
ACCESSORIES. All powered wheelchair accessories not defined in this rule as
Power Seating Accessories are excluded from TennCare coverage but may be
provided by an MCO as a cost effective alternative service as defined in this
rule.
(104) PREMIUM. A specified
amount of money that an insured person is required to pay on a regular basis in
order to participate in a health plan.
(105) PRESCRIBER. An individual authorized by
law to prescribe drugs.
(106)
PRIMARY CARE PHYSICIAN shall mean a physician responsible for supervising,
coordinating, and providing initial and primary care to patients; for
initiating referrals for specialist care; and for maintaining the continuity of
patient care. A primary care physician is a physician who has limited his
practice of medicine to general practice or who is a Board Certified or
Eligible Internist, Pediatrician, Obstetrician/Gynecologist, or Family
Practitioner.
(107) PRIMARY CARE
PROVIDER shall mean health care professional capable of providing a wide
variety of basic health services. Primary care providers include practitioners
of family , general, or internal medicine; pediatricians and obstetricians;
nurse practitioners; midwives; and physician's assistant in general or family
practice.
(108) PRIOR APPROVAL
STATUS shall mean the restriction of an enrollee to a procedure wherein
services, except in emergency situations, must be approved by the TennCare
Bureau or the MCC prior to the delivery of services.
(109) PRIOR AUTHORIZATION shall mean the
process under which services, except in emergency situations, must be approved
by the TennCare Bureau or the MCC prior to the delivery in order for such
services to be covered by the TennCare program.
(110) PRIVATE DUTY NURSING SERVICES shall
mean nursing services for recipients who require eight (8) or more hours of
continuous skilled nursing care during a 24-hour period.
(a) A person who needs intermittent skilled
nursing functions at specified intervals, but who does not require continuous
skilled nursing care throughout the period between each interval, shall not be
determined to need continuous skilled nursing care. Skilled nursing care is
provided by a registered nurse or licensed practical nurse under the direction
of the recipient's physician to the recipient and not to other household
members. If there is more than one person in a household who is determined to
require TennCare-reimbursed private duty nursing services, it is not necessary
to have multiple nurses providing the services. A single nurse may provide
services to multiple enrollees in the same home and during the same hours, as
long as he can provide these services safely and appropriately to each
enrollee.
(b) If it is determined
by the MCO to be cost-effective, non-skilled services may be provided by a
nurse rather than a home health aide. However, it is the total number of hours
of skilled nursing services, not the number of hours that the nurse is in the
home, that determines whether the nursing services are continuous or
intermittent.
(c) Private duty
nursing services are covered for adults aged 21 and older only when medically
necessary to support the use of ventilator equipment or other life-sustaining
medical technology when constant nursing supervision, visual assessment, and
monitoring of both equipment and patient are required. For purposes of this
rule, an adult is considered to be using ventilator equipment or other
life-sustaining medical technology if he:
1.
Is ventilator dependent for at least 12 hours each day with an invasive patient
end of the circuit (i.e., tracheostomy cannula); or
2. Is ventilator dependent with a progressive
neuromuscular disorder or spinal cord injury, and is ventilated using
noninvasive positive pressure ventilation (NIPPV) by mask or mouthpiece for at
least 12 hours each day in order to avoid or delay tracheostomy (requires
medical review); or
3. Has a
functioning tracheostomy:
(i) Requiring
suctioning; and
(ii) Oxygen
supplementation; and
(iii)
Receiving nebulizer treatments or requiring the use of Cough
Assist/in-exsufflator devices; and
(iv) In addition, at least one subitem from
each of the following items [(I) and (II)] must be met:
(I) Medication:
I. Receiving medication via a gastrostomy
tube (G-tube); or
II. Receiving
medication via a Peripherally Inserted Central Catheter (PICC) line or central
port; and
(II)
Nutrition:
I. Receiving bolus or continuous
feedings via a permanent access such as a G-tube, Mickey Button, or
Gastrojejunostomy tube (G-J tube); or
II. Receiving total parenteral
nutrition.
(d) Private duty nursing services are covered
as medically necessary for children under the age of 21 in accordance with
EPSDT requirements. As a general rule, only a child who is dependent upon
technology-based medical equipment requiring constant nursing supervision,
visual assessment, and monitoring of both equipment and child will be
determined to need private duty nursing services. However, determinations of
medical necessity will continue to be made on an individualized
basis.
(e) A child who needs less
than eight (8) hours of continuous skilled nursing care during a 24-hour period
or an adult who needs nursing care but does not qualify for private duty
nursing care per the requirements of these rules may receive medically
necessary nursing care as an intermittent service under home health.
(f) General childcare services and other
non-hands-on assistance such as cleaning and meal preparation shall not be
provided by a private duty nurse. Because children typically have non-medical
care needs which must be met, to the extent that private duty nursing services
are provided to a person or persons under 18 years of age, a responsible adult
(other than the private duty nurse) must be present at all times in the home
during the provision of private duty nursing services unless all of the
following criteria are met:
1. The child is
non-ambulatory; and
2. The child
has no or extremely limited ability to interact with caregivers; and
3. The child shall not reasonably be expected
to have needs that fall outside the scope of medically necessary TennCare
covered benefits (e.g., the child has no need for general supervision or meal
preparation) during the time the private duty nurse is present in the home
without the presence of another responsible adult; and
4. No other children shall be present in the
home during the time the private duty nurse is present in the home without the
presence of another responsible adult, unless these children meet all of the
criteria stated above and are also receiving TennCare-reimbursed private duty
nursing services .
(111) PROVIDER shall mean an appropriately
licensed institution, facility, agency, person , corporation, partnership, or
association that delivers health care services. Providers are categorized as
either TennCare Providers or Non-TennCare Providers. TennCare Providers may be
further categorized as being one of the following:
(a) Participating Providers or In-Network
Provider s
(b) Non-Participating
Providers or Out-of-Network Provider s
(c) Out-of-State Emergency Providers
Definitions of each of these terms are contained in this Rule.
(112) PROVIDER -INITIATED
REDUCTION, TERMINATION OR SUSPENSION OF SERVICES shall mean a decision to
reduce, terminate, or suspend an enrollee 's TennCare services which is
initiated by the enrollee 's provider, rather than by the MCC.
(113) PROVIDER WITH PRESCRIBING AUTHORITY
shall mean, in the context of TennCare pharmacy services, a health care
professional authorized by law or regulation to order prescription medications
for his/her patients, and who:
(a)
Participates in the provider network of the MCC in which the enrollee is
enrolled; or
(b) Has received a
referral of the enrollee , approved by the MCC, authorizing her to treat the
enrollee; or
(c) In the case of a
TennCare enrollee who is also enrolled in Medicare, is authorized to treat
Medicare patients.
(114)
PRUDENT LAY PERSON shall mean a reasonable person who possesses an average
knowledge of health and medicine.
(115) QUALIFIED UNINSURED PERSON shall mean
an uninsured person who meets the technical, financial, and insurance
requirements for the TennCare Standard Program.
(116) QUALIFYING MEDICAL CONDITION shall mean
a medical condition which is included among a list of conditions established by
the Bureau and which will render a qualified uninsured applicant medically
eligible .
(118) REASSIGNMENT shall mean the process by
which the Bureau of TennCare transfers an enrollee from one MCO to another as
described in these rules.
(119)
RECEIPT OF MAILED NOTICES shall mean that receipt of mailed notices is presumed
to occur within five (5) days of mailing.
(120) RECERTIFICATION shall have the same
meaning as Redetermination .
(121)
RECONSIDERATION shall mean the mandatory process, triggered by an enrollee 's
request for a SFH, by which an MCC reviews and renders a decision affirming or
reversing the MCC's adverse benefit determination. An MCC satisfies the
plan-level requirements of 42 C.F.R. Part 438 Subpart F when the review
includes all available , relevant, clinical documentation (including
documentation which may not have been considered in the original review); is
performed by a physician other than the original reviewing physician; and
produces a timely written finding. See June 5, 2017, CMS letter from Jackie
Glaze to Wendy Long, M.D., M.P.H.
(122) REDETERMINATION shall mean the process
by which DHS evaluates the ongoing eligibility status of TennCare Medicaid and
TennCare Standard enrollees. This is a periodic process that is conducted at
specified intervals or when an enrollee 's circumstances change. The process is
conducted in accordance with TennCare's, or its designee's, policies and
procedures.
(123) REQUEST FOR
REIMBURSEMENT shall mean a request from an enrollee for reimbursement of
amounts paid out of pocket to providers for medical, dental or pharmacy
services received. Enrollees seeking reimbursement are required to submit
receipts or bills that include the following information: the amount paid by
enrollee , a description of the prescriptions, care or services received, the
date the prescriptions, care or services were received, and the name of the
provider or pharmacy. All required information must be received from enrollees
within the sixty (60) day timeframe to request reimbursement as prescribed by
Rule 1200-13-14-.11(2)(d).
(124) RESPONSIBLE PARTY(IES) shall mean the
following individuals, who are representatives and/or relatives of recipients
of medical assistance who are not financially eligible to receive benefits :
parents, spouses, children, and guardians; as defined at Tennessee Code
Annotated §
71-5-103(10).
(125) SSI (SUPPLEMENTAL SECURITY INCOME )
BENEFITS shall mean the benefits provided through a program administered by the
Social Security Administration for those meeting program eligibility
requirements. Tennessee residents determined eligible for SSI benefits are
automatically enrolled in TennCare Medicaid.
(126) STANDARD SPEND DOWN (SSD) shall mean
the demonstration eligibility category composed of adults age twenty-one (21)
and older who have been found to meet the criteria in Rule
1200-13-14-.02.
(127) STATE FAIR HEARING (SFH) shall mean an
evidentiary hearing requested by or on behalf of an enrollee to allow the
enrollee to appeal an adverse benefit determination, which is conducted in
accordance with 42 C.F.R. Part 431 Subpart E and the Tennessee Uniform
Administrative Procedures Act, T.C.A. §§
4-5-301,
et seq. An initial order under T.C.A. §
4-5-314
shall be entered when an evidentiary hearing is held before a hearing officer .
If any party appeals the initial order under T.C.A. §
4-5-315,
the Commissioner may render a final order.
(128) TARGETED PHARMACY. A pharmacy meeting
one of the following criteria:
(a) It is
located outside the State of Tennessee.
(b) It has had previous controlled substance
violations with the Tennessee State Board of Pharmacy.
(c) It appears to be an outher to the norm in
its dispensing of controlled substances.
(d) It has filled controlled substance
prescriptions that are covered by TennCare for members locked in to a different
pharmacy after being notified that the member was locked in to a different
pharmacy.
(129) TARGETED
PRESCRIBER. A prescriber with prescribing authority who is ranked as a top
prescriber of controlled substances based on multiple factors which may include
but are not limited to any of the following:
(a) The percentage of controlled substances
prescribed.
(b) The percentage of
Schedule II controlled substances prescribed.
(c) The percentage of Schedule III controlled
substances prescribed.
(d) The
percentage of short acting single ingredient opiates prescribed.
(e) The percentage of short acting
combination product opiates prescribed.
(f) The percentage of long acting opiates
prescribed.
(g) The average
morphine equivalents per day prescribed.
(h) The percentage of rejected claims of
controlled substances.
(130) TECHNICAL ELIGIBILITY REQUIREMENTS
shall mean the eligibility requirements applicable to the appropriate category
of medical assistance as discussed in Chapter 1240-03-03.03 of the rules of the
TDHS - Division of Medical Services, and the additional eligibility
requirements set forth in these rules.
(131) TENNCARE shall mean the program
administered by the Single State agency as designated by the State and CMS
pursuant to Title XIX of the Social Security Act and the Section 1115 Research
and Demonstration waiver granted to the State of Tennessee.
(132) TENNCARE APPEAL FORM shall mean the
TennCare form(s) which are completed by an enrollee or by a person authorized
by the enrollee to do so, when an enrollee appeals an adverse benefit
determination.
(133) TENNCARE
CHOICES in Long-Term Care shall mean the program described in Rule 1
20013-01-.05.
(134) TENNCARE
MEDICAID shall mean that part of the TennCare program, which covers persons
eligible for Medicaid under Tennessee's Title XIX State Plan for Medical
Assistance. The following persons are eligible for TennCare Medicaid:
(a) Tennessee residents determined to be
eligible for Medicaid in accordance with 124003-03 of the rules of the
Tennessee Department of Human Services - Division of Medical
Services.
(b) Individuals who
qualify as dually eligible for Medicare and Medicaid are enrolled in TennCare
Medicaid.
(c) A Tennessee resident
who is an uninsured woman, under age sixty-five (65), a US citizen or qualified
alien, is not eligible for any other category of Medicaid, has been diagnosed
as the result of a screening at a Centers for Disease Control and Prevention
(CDC) site with breast or cervical cancer, including pre-cancerous
conditions.
(d) Tennessee residents
determined eligible for SSI benefits by the Social Security Administration are
automatically enrolled in TennCare Medicaid.
(135) TENNCARE MEDICAID ELIGIBILITY REFORMS
shall mean the amendments to the TennCare demonstration project approved by CMS
on March 24, 2005, to close enrollment into TennCare Medicaid for non-pregnant
adults age twenty-one (21) or older who qualify as Medically Needy under
Tennessee's Title XIX State Plan for Medical Assistance and to disenroll
non-pregnant adults age twenty-one (21) or older who qualify as Medically Needy
under Tennessee's Title XIX State Plan for Medical Assistance after completion
of their twelve (12) months of eligibility.
(136) TENNCARE PHARMACY PROGRAMS shall mean
any TennCare pharmacy carve-outs, including, but not limited to, enrollees with
dual eligibility and all pharmacy services provided by the TennCare Managed
Care Organizations (MCOs).
(137)
TENNCARE PROVIDER shall mean a provider who accepts as payment in full for
furnishing benefits to a TennCare enrollee, the amounts paid pursuant to an
approved agreement with an MCC or TennCare. Such payment may include copayments
from the enrollee or the enrollee's responsible party. TennCare providers must
be enrolled with TennCare. TennCare providers must abide by all TennCare rules
and regulations, including requirements regarding provider billing of patients
as found in Rule
1200-13-14-.08. TennCare
providers must be appropriately licensed for the services they deliver and must
not be providers who have been excluded from participation in Medicare or
Medicaid .
(138) TENNCARE SELECT
shall mean a state self-insured HMO established by the Bureau of TennCare and
administered by a contractor to provide medical services to certain eligible
enrollees.
(139) TENNCARE SERVICES
OR BENEFITS for purposes of this rule shall mean any medical assistance that is
administered by the Bureau of TennCare or its contactors and which is funded
wholly or in part with federal funds under the Medicaid Act or any waiver
thereof, but excluding:
(a) Medical
assistance that can be appealed through an appeal of a pre-admission evaluation
(PAE) determination; and
(b)
Medicare cost sharing services that do not involve utilization review by the
Bureau of TennCare or its contractors.
(140) TENNCARE STANDARD shall mean that part
of the TennCare Program which provides health coverage for Tennessee residents
who are not eligible for Medicaid and who meet the eligibility criteria found
in rule 1200-13-14-.02.
(141) TENNCARE STANDARD ELIGIBILITY REFORMS
shall mean the amendments to the TennCare demonstration project approved by CMS
on March 24, 2005, to terminate coverage for adults aged 19 and older in
TennCare Standard eligibility groups.
(142) TENNderCARE shall mean the name given
to the preventive health care program for TennCare children.
(143) TERMINATION shall mean the
discontinuance of an enrollee 's coverage under the TennCare Medicaid or
TennCare standard program.
(144)
THIRD PARTY shall mean any entity or funding source other than the enrollee or
his/her responsible party, which is or may be liable to pay for all or a part
of the costs of medical care of the enrollee .
(145) TRANSITION GROUP shall mean existing
Medically Needy adults age twenty-one (21) or older enrolled as of October 5,
2007, who have not yet been assessed for transition to the Standard Spend Down
Demonstration population for non-pregnant adults age twenty-one (21) or
older.
(146) TREATING PHYSICIAN (OR
CLINICIAN) shall mean a health care provider who has provided diagnostic or
treatment services for an enrollee (whether or not those services were covered
by TennCare), for purposes of treating, or supporting the treatment of, a known
or suspected medical condition. The term excludes providers who have evaluated
an enrollee 's medical condition primarily or exclusively for the purposes of
supporting or participating in a decision regarding TennCare
coverage.
(147) UNINSURED shall
mean any person who does not have health insurance directly or indirectly
through another family member, or who does not have access to group health
insurance. For purposes of the Medicaid eligibility category of women under 65
requiring treatment for breast or cervical cancer, "Uninsured" shall mean any
person who does not have health insurance or access to health insurance which
covers treatment for breast or cervical cancer.
(148) VALID FACTUAL DISPUTE shall mean a
dispute which, if resolved in favor of the enrollee , would result in the
proposed action not being taken.
Notes
Authority: T.C.A. §§ 4-5-202, 4-5-208, 4-5-209, 71-5-105, 71-5-107, 71-5-109, 71-5-113, 71-5-134, and 71-5-146; 42 C.F.R. Part 431 Subpart E; 42 C.F.R. Part 438 Subpart F; 42 C.F.R. Part 455 Subpart E; and Executive Order No. 23.
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