Tenn. Comp. R. & Regs. 1200-11-01-.05 - AUTHORIZATION AND REIMBURSEMENT FOR SERVICES
(1)
No payment shall be made for services rendered to any participant under these
Rules unless and until all third party payment sources available have been
exhausted.
(2) Payment for
out-of-state dialysis services must be prior approved and is limited to six (6)
dialysis treatments within any twelve (12) month period.
(3) The Department will pay one hundred
percent (100%) of the Medicare allowable reimbursement rate for in-center
dialysis during that portion of the Medicare waiting period before patients are
eligible for Medicare benefits, if the patient does not have health insurance
coverage and is not eligible for TennCare benefits. If the patient has only
health insurance coverage, the amount which will be paid will be equal to the
Medicare allowable reimbursement rate, less any insurance payments.
(4) The Department will reimburse pharmacists
for routine renal drugs in an amount not to exceed a set monthly cap,
established by the Commissioner based upon the availability of funds. The
Commissioner will establish caps for expenditures for those participants who
are covered by TennCare and for those who are covered by Medicare
only.
(5) Dental services must have
prior authorization and will be reimbursed based on the Schedule of Allowances
of United Concordia Companies, Inc. (Blue Cross/Blue Shield of
Pennsylvania).
(6) All services
provided under these Rules are to be obtained within the state, except for
services provided to participants who have received prior authorization for
out-of-state treatment.
Notes
Authority: T.C.A. ยงยง 68-35-103 and 4-5-202.
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