Section 1200-13-16-.03 - THE SCOPE OF TENNCARE'S PAYMENT OBLIGATION(1) Tennessee has an obligation to provide payment on behalf of TennCare enrollees for and only for (a) covered services (b) that are medically necessary.(2) No TennCare enrollee is entitled to receive (a) non-covered services including cost effective alternative services or (b) covered services that are not medically necessary.(3) In the context of prior authorization or concurrent review:(a) When a covered service has been designated by the Bureau of TennCare or a managed care contractor as requiring prior approval, no TennCare enrollee is entitled to receive the covered service until the favorable conclusion of the prior approval process.(b) When a covered service has been designated by the Bureau of TennCare or a managed care contractor as requiring concurrent review, the enrollee may receive covered services until the expiration of any existing authorization for treatment or until a determination that such service is no longer medically necessary. No TennCare enrollee is entitled to receive covered services subject to concurrent review beyond the expiration of any existing authorization for treatment unless such authorization has been extended through the concurrent review process. For TennCare enrollees under age 21, upon receipt of a timely filed request to continue authorization of a service originally prescribed on an ongoing basis, such authorization is automatically extended pending completion of concurrent review. A request to continue authorization shall be timely if received by the MCC prior to the expiration of the current authorization.Tenn. Comp. R. & Regs. 1200-13-16-.03
Public necessity rule filed December 1, 2006; expires May 15, 2007. Original rule filed March 1, 2007; effective May 15, 2007.Authority: T.C.A. §§ 4-5-209, 71-5-105, 71-5-109, Executive Order No. 23.