Section 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.Tenn. Comp. R. & Regs. 1200-11-01-.05
Original rule certified June 7, 1974. Amendment filed July 22, 1976; effective August 21, 1976. Amendment filed July 22, 1977; effective August 22, 1977. Repeal and new rule filed October 9, 1985; effective January 14, 1986. Amendment filed June 8, 1989; effective July 14, 1989. Amendment filed September 25, 1990; effective December 29, 1990. Amendment filed January 29, 1992; effective April 29, 1992. Amendment filed May 10,1995; effective September 28, 1995. Repeal and new rule filed September 17, 1998; effective January 28, 1999.Authority: T.C.A. §§ 68-35-103 and 4-5-202.