Payment in full.
(a) All Participating Providers, as defined
in this Chapter, must accept as payment in full for provision of covered
services to TennCare enrollees, the amounts paid by the MCC plus any copayment
required by the TennCare Program to be paid by the individual.
(b) Any Non-Participating Providers who
provide TennCare Program covered services by authorization from an MCC must
accept as payment in full for provision of covered services to TennCare
enrollees, the amounts paid by the MCC plus any copayment required by the
TennCare Program to be paid by the individual.
Any Non-Participating Provider, as
defined in this Chapter, who provides TennCare Program covered non-emergency
services to TennCare enrollees without authorization from the enrollee's MCC
does so at his own risk. He may not bill the patient for such services except
as provided for in Rule
(d) Any Out-of-State Emergency Provider, as
defined in this Chapter, who provides covered emergency services to TennCare
enrollees in accordance with this Chapter must accept as payment in full the
amounts paid by the MCC plus any copayment required by the TennCare
situations where a MCC authorizes a service to be rendered by a provider who is
not a Participating Provider with the MCC, as defined in this Chapter, payment
to the provider shall be no less than eighty percent (80%) of the lowest rate
paid by the MCC to equivalent participating network providers for the same
necessary outpatient emergency services, when provided to Medicaid managed care
enrollees by non-contract hospitals in accordance with Section 1932(b)(2)(D) of
the Social Security Act (42 U.S.C.
A. § 1396u-2(b)(2)(D)), shall be
reimbursed at seventy-four percent (74%) of the 2006 Medicare rates for these
services. Emergency care to enrollees shall not require
medically necessary inpatient hospital admissions required as the result of
emergency outpatient services, when provided to Medicaid managed care enrollees
by non-contract hospitals in accordance with Section 1932(b)(2)(B) of the
Social Security Act (42 U.S.C.
A. § 1396u-2(b)(2)(B)), shall be reimbursed
at 57 percent of the 2008 Medicare Diagnostic Related Groups (DRG) rates
(excluding Medical Education and Disproportionate Share components) determined
in accordance with 42 CFR
those services. For DRG codes
that are adopted after 2008, 57 percent of the rate from the year of adoption
will apply. Such an inpatient stay will continue until no longer medically
necessary or until the patient can be safely transported to a contract hospital
or to another contract service, whichever comes first.
Non-Participating Providers who furnish
covered CHOICES services are reimbursed in accordance with Rule
(e) Non-Participating Providers who furnish
covered ECF CHOICES services are reimbursed in accordance with Rule
Participation in the TennCare program will be limited to providers who:
(a) Accept, as payment in full, the amounts
paid by the managed care contractor, including copays from the enrollee, or the
amounts paid in lieu of the managed care contractor by a third party (Medicare,
Tennessee, or the State in which they practice, medical licenses and/or
certifications as required by their practice, or licensure by the TDMHDD, if
(c) Are not under a
federal Drug Enforcement Agency (DEA) restriction of their prescribing and/or
dispensing certification for scheduled drugs (relative to physicians,
osteopaths, dentists and pharmacists);
(d) Agree to maintain and provide access to
TennCare and/or its agent all TennCare enrol-lee medical records for five (5)
years from the date of service or upon written authorization from TennCare
following an audit, whichever is shorter;
(e) Provide medical assistance at or above
recognized standards of practice; and
(f) Comply with all contractual terms between
the provider and the managed care contractor and TennCare policies as outlined
in federal and state rules and regulations and TennCare provider manuals and
Failure to comply
with any of the above provisions (a) through (f) may subject a provider to the
1. Sanctions set out in
71-5-118. In addition, the
provider may be subject to stringent review/audit procedures, which may include
clinical evaluation of services and a prepayment requirement for documentation
and justification for each claim.
2. The Bureau of TennCare may withhold or
recover payments to managed care contractors in cases of provider fraud,
willful misrepresentation, or flagrant non-compliance with contractual
requirements and/or TennCare policies.
3. The Bureau of TennCare may refuse to
approve or may suspend provider participation with a provider if any person who
has an ownership or controlling interest in the provider, or who is an agent or
managing employee of the provider, has been convicted of a criminal offense
related to that person's involvement in any program established under Medicare,
Medicaid or the US Title XX Services Program.
4. The Bureau of TennCare may refuse to
approve or may suspend provider participation if it determines that the
provider did not fully and accurately make any disclosure of any person who has
ownership or controlling interest in the provider, or is an agent or managing
employee of the provider and has been convicted of a criminal offense related
to that person's involvement in any program under Medicare, Medicaid or the US
Title XX Services Program since the inception of these programs.
5. The Bureau of TennCare shall refuse to
approve or shall suspend provider participation if the appropriate State Board
of Licensing or Certification fails to license or certify the provider at any
time for any reason or suspends or revokes a license or
6. The Bureau of
TennCare shall refuse to approve or shall suspend provider participation upon
notification by the US Office of Inspector General Department of Health and
Human Services that the provider is not eligible under Medicare or Medicaid for
federal financial participation.
The Bureau of TennCare may recover from a managed care contractor any payments
made by an enrollee and/or his family for a covered service, in total or in
part, except as permitted. If a provider knowingly bills an enrollee and/or his
family for a covered service, in total or in part, except as permitted, the
Bureau of TennCare may terminate the provider's participation in
Solicitations and Referrals.
(a) Managed care
contractors and providers shall not solicit TennCare enrollees by any method
offering as enticements other goods and services (free or otherwise) for the
opportunity of providing the enrollee with TennCare covered services that are
not medically necessary and/or that overutilize the TennCare program.
(b) A managed care contractor may request a
waiver from this restriction in writing to TennCare. TennCare shall determine
the value of a waiver request based upon the medical necessity and need for the
solicitation. The managed care contractor may implement the solicitation only
upon receipt of a written waiver approval from TennCare. This waiver is not
transferable and may be canceled by TennCare upon written notice.
(c) TennCare payments for services related to
a non-waivered solicitation enticement shall be considered by TennCare as a
non-covered service and recouped. Neither the managed care contractor nor the
provider may bill the enrollee for non-covered services recouped under this
(d) A provider shall not
offer or receive remuneration in any form related to the volume or value of
referrals made or received from or to another provider.
Providers may seek payment from a
TennCare enrollee only under the following circumstances. These circumstances
apply to all TennCare providers, as defined in this Chapter, including those
who are Out-of-Network Providers in a particular enrollee's MCC. These
circumstances include situations where the enrollee may choose to seek an
out-of-network provider for a specific covered service.
(a) If the services are not covered by the
TennCare program and, prior to providing the services, the provider informed
the enrollee that the services were not covered; or
If the services are not covered because
they are in excess of an enrollee's benefit limit and one of the following
1. The provider
determines effective on the date of service that the enrollee has reached
his/her benefit limit for the particular service being requested and, prior to
providing the service, informs the enrollee that the service is not covered and
the service will not be paid for by TennCare. The source of the provider's
information must be a database listed on the TennCare website as approved by
TennCare on the date of the provider's inquiry.
The provider has information in his/her
own records to support the fact that the enrollee has reached his/her benefit
limit for the particular service being requested and, prior to providing the
service, informs the enrollee that the service is not covered and will not be
paid for by TennCare. This information may include:
(i) A previous written denial of a claim on
the basis that the service was in excess of the enrollee's benefit limit for a
service within the same benefit category as the service being requested, if the
time period applicable to the benefit limit is still in effect; or
(ii) That the provider had previously
examined the database referenced in part 1. above and determined that the
enrollee had reached his/her benefit limit for the particular service being
requested, if the time period applicable to that benefit limit is still in
(iii) That the provider
had personally provided services to the enrollee in excess of his/her benefit
limit within the same benefit category as the service being requested, if the
time period applicable to that benefit period is still in effect; or
(iv) The enrollee's MCO has provided
confirmation to the provider that the enrollee has reached his/her benefit
limit for the applicable service.
3. The provider submits a claim for service
to the appropriate managed care contractor (MCC) and receives a written denial
of that claim on the basis that the service exceeds the enrollee's benefit
limit. Thereafter, following informing the enrollee and within the remainder of
the period applicable to that benefit limit, the provider may bill the enrollee
for services within that same exhausted benefit category without having to
submit, for repeated MCC denial, claims for those subsequent services. If the
provider informed the enrollee prior to providing the service for which the
claim was denied that the service would exceed the enrollee's benefit limit and
would not be paid for by TennCare, the provider may bill the enrollee for that
4. The provider had
previously taken the steps in parts 1., 2. or 3. above and determined that the
enrollee had reached his/her benefit limit for the particular service being
requested, if the time period applicable to the benefit limit is still in
effect, and informs the enrollee, prior to providing the service, that the
service is not covered and will not be paid for by TennCare.
(c) If the services are covered
only with prior authorization and prior authorization has been requested but
denied, or is requested and a specified lesser level of care is approved, and
the provider has given prior notice to the enrollee that the services are not
covered, the enrollee may elect to receive those services for which prior
authorization has been denied or which exceed the authorized level of care and
be billed by the provider for such services.
Providers may not seek payment from a
TennCare enrollee under the following conditions:
(a) The provider knew or should have known
about the patient's TennCare eligibility or pending eligibility prior to
claim(s) submitted to TennCare or the enrollee's managed care contractor for
payment was denied due to provider billing error or a TennCare claim processing
(c) The provider accepted
TennCare assignment on a claim and it is determined that another payer paid an
amount equal to or greater than the TennCare allowable amount.
(d) The provider failed to comply with
TennCare policies and procedures or provided a service which lacks medical
necessity or justification.
provider failed to submit or resubmit claims for payment within the time
periods required by the managed care contractor or TennCare.
(f) The provider failed to ascertain the
existence of TennCare eligibility or pending eligibility prior to providing
non-emergency services. Even if the enrollee presents another form of
insurance, the provider must determine whether the patient is covered under
The provider failed
to inform the enrollee prior to providing a service not covered by TennCare
that the service was not covered and the enrollee may be responsible for the
cost of the service. Services which are non-covered by virtue of exceeding
limitations are exempt from this requirement. Notwithstanding this exemption,
providers shall remain obligated to provide notice to enrollees who have
exceeded benefit limits in accordance with rule
(h) The enrollee failed to keep a scheduled
(i) The provider is
a TennCare provider, as defined in this Chapter, but is not participating with
a particular enrollee's MCC and is seeking to bill the enrollee as though the
provider were a Non-TennCare Provider, as defined in this Chapter.
(7) Providers may seek payment
from a person whose TennCare eligibility is pending at the time services are
provided if the provider informs the person that TennCare assignment will not
be accepted whether or not eligibility is established retroactively.
(8) Providers may seek payment from a person
whose TennCare eligibility is pending at the time services are provided.
Providers may bill such persons at the provider's usual and customary rate for
the services rendered. However, all monies collected for TennCare-covered
services rendered during a period of TennCare eligibility must be refunded when
a claim is submitted to TennCare if the provider agreed to accept TennCare
assignment once retroactive TennCare eligibility was established.
(9) Providers of inpatient hospital services,
outpatient hospital services, skilled nursing facility services, independent
laboratory and x-ray services, hospice services, and home health agencies must
be approved for Title XVIII-Medicare in order to be certified as providers
under the TennCare Program; in the case of hospitals, the hospital must meet
state licensure requirements and be approved by TennCare as an acute care
hospital as of the date of enrollment in TennCare. Children's hospitals and
State mental hospitals may participate in TennCare without having been Medicare
approved; however, the hospital must be approved by the Joint Commission for
Accreditation of Health Care Organizations as a condition of
providers may not waive pharmacy copayments for TennCare Medicaid or TennCare
Standard enrollees as a means of attracting business to their establishment.
This does not prohibit a pharmacy from exercising professional judgment in
cases where an enrol-lee may have a temporary or acute need for a prescribed
drug, but is unable, at that moment, to pay the required copayment.
(11) Providers shall not deny services for
Medicaid enrollee failure to make copayments.
All claims must be filed in accordance
with the following:
(a) Claims filed with an
MCC must be submitted in accordance with the requirements and timeframes set
forth in the MCC's contract.
All other fee-for-service claims for services delivered outside of the TennCare
managed care program must be filed with the Bureau of TennCare as follows:
All claims must be filed within one (1)
year of the date of service except in the following circumstances:
(i) Recipient eligibility was determined
retroactively to the extent that filing within one (1) year was not possible.
In such situations, claims must be filed within one (1) year after final
determination of eligibility.
If a claim filed with Medicare on a timely basis does not automatically cross
over from the Medicare carrier to the Bureau, a TennCare claim may be filed
within six (6) months of notification of payment or denial from
2. Should an
original claim be denied, any resubmission or follow-up of the initial claim
must be received within six (6) months from the date the original claim was
filed. The Bureau will not process submissions received after the six (6) month
time limit. The one exception is those claims returned due to available third
party coverage. These claims must be submitted within sixty (60) days of notice
from the third party resource.
Should a correction document involving a suspended claim be sent to the
provider, the claim will be denied if the correction document is not completed
by the provider and returned to the Bureau within ninety (90) days from the
date on the document.
4. If claim
is not filed within the above timeframes, no reimbursement may be
5. Claims will be paid on a
first claim approved - first claim paid basis.
6. The Bureau will not reimburse providers
for services for which there is no Federal Financial Participation.