Tenn. Comp. R. & Regs. 1200-13-17-.04 - MEDICARE CROSSOVER PAYMENT METHODOLOGY

Notwithstanding anything in these rules to the contrary, TennCare's payment methodology for crossover claims submitted on behalf of FBDEs and non-FBDE QMBs for professional services delivered under either Medicare Part B or Medicare Part C is as follows:

(1) On crossover claims for professional services and procedures with dates of service on or after July 1, 2008, TennCare will pay the TennCare allowable, as defined in these rules, less the Medicare paid amount, less any third party liability.
(2) On crossover claims for Medicare Part B pharmacy services provided by pharmacy providers, as defined in these rules, to non-FBDEs with dates of service on or after July 1, 2009, TennCare will pay the TennCare allowable, as defined in these rules, less the Medicare paid amount, less any third party liability.
(3) On crossover claims for Medicare Part B pharmacy services provided by pharmacy providers, as defined in these rules, to FBDEs with dates of service on or after July 1, 2009, TennCare will pay the TennCare pharmacy allowable, as defined in these rules, less the Medicare paid amount, less any third party liability.
(4) In no circumstance will the TennCare payment exceed the enrollee's liability on the Medicare crossover claim.
(5) Medicare crossover payments are normally made by the Bureau of TennCare separately from the Managed Care Contractors. Rules 1200-13-13-.08(12)(b) and 1200-13-14-.08(12)(b) set forth the guidelines for timely filing Medicare crossover claims. However, if an MCC should choose to authorize a non-covered TennCare service as a cost-effective alternative service for a non-QMB FBDE who is age 21 or older and not an SSI recipient, the MCC will be responsible for the Medicare crossover payment on that service. The calculation of this payment should be included by the MCC in its analysis of whether or not the non-covered TennCare service is a cost-effective alternative service.

Notes

Tenn. Comp. R. & Regs. 1200-13-17-.04
Public necessity rule filed July 1, 2008; effective through December 13, 2008. New rule filed September 24, 2008; effective December 8, 2008. Public necessity rule filed July 1, 2009; effective through December 13, 2009. Amendment filed September 11, 2009; effective December 10, 2009. Emergency rule filed March 1, 2010; effective through August 28, 2010. Amendment filed May 27, 2010; effective August 25, 2010.

Authority: T.C.A. 4-5-202, 4-5-208, 71-5-105, and 71-5-109.

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