Section 0780-01-73-.02 - PURPOSE AND SCOPE(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.Tenn. Comp. R. & Regs. 0780-01-73-.02
Original rule filed April 4, 2002; effective June 18, 2002.Authority: T.C.A. § 56-32-218(a) and Public Acts of 2001, Chapter 209, § 1.