Rules & Regulations of the State of Tennessee
Title 0780 - Commerce and Insurance
Subtitle 0780-01 - Insurance Division
Chapter 0780-01-73 - Uniform Claims Process for TennCare Participating Managed Care Organizations
Section 0780-01-73-.02 - PURPOSE AND SCOPE
Universal Citation: TN Comp Rules and Regs 0780-01-73-.02
Current through September 24, 2024
(1) Purpose. These rules designate a uniform TennCare claims process, which contains standardized instructions for completing the form and creates standardized responses to questions and other information required on the form, for providers and managed care organizations participating in the TennCare program to use in the submission of claims by providers seeking payment.
(2) Scope. These rules apply to the TennCare bureau, TennCare program and TennCare Partners program health claims and encounter data reporting.
(a) Except as
otherwise specifically provided, the requirements of these rules apply to
TennCare health maintenance organizations (HMOs), TennCare Partners program
behavioral health organizations (BHOs), TennCare program providers, and
TennCare Partners program providers that contract directly with the State and
have claims processing responsibility, including, but not limited to, TennCare
program and TennCare Partners program prepaid limited health service
organizations (PLHSOs).
(b) These
rules do not prohibit an issuer from requesting additional information required
to determine eligibility of the claim under the terms and conditions of the
TennCare program or the TennCare Partners program.
(c) These rules do not prohibit an HMO, BHO,
or provider from using capitation payment methodology, daily rate methodology
or other similar arrangements for compensating providers.
(d) These rules do not exempt a provider or
HMO or BHO from data reporting requirements under state or federal law or
regulation.
Authority: T.C.A. § 56-32-218(a) and Public Acts of 2001, Chapter 209, § 1.
Disclaimer: These regulations may not be the most recent version. Tennessee may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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