(a)

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Terms Used In Tennessee Code 71-5-191

  • Amendment: A proposal to alter the text of a pending bill or other measure by striking out some of it, by inserting new language, or both. Before an amendment becomes part of the measure, thelegislature must agree to it.
  • Medical assistance: means payment of the cost of care, services and supplies necessary to prevent, diagnose, correct or cure conditions in the person that cause acute suffering, endanger life, result in illness or infirmity, interfere with the person's capacity for normal activity, or threaten some significant handicap and that are furnished an eligible person in accordance with this part and the rules and regulations of the department. See Tennessee Code 71-5-103
(1) Not later than January 1, 2002, the commissioner of commerce and insurance, in consultation with the commissioner of health, shall develop and promulgate by rule a uniform TennCare claims process that 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. Each managed care organization, or its designee that participates in the TennCare program may participate in the development of such uniform claims process. The commissioner of commerce and insurance shall notify all such managed care organizations no less than ten (10) days prior to any and all meetings concerning the development of such claims process to enable such organizations to provide input on the development of such claims process. The uniform process shall require that managed care organizations participating in the TennCare program shall not deviate from the uniform process established by rule pursuant to this section, unless such deviation is specifically approved in writing by TennCare prior to any change being implemented that might result in a claim being rejected for payment. TennCare shall not approve any changes to standardized instructions that do not relate to using alternative codes to facilitate payment for delivered services. Compliance with this section shall be added as a component of the comptroller’s annual audit. In addition, such managed care organizations shall be required to develop and implement procedures to ensure that health care providers are regularly informed and educated by the managed care organization regarding billing and claims processing procedures.
(2) Any managed care organization that fails to comply with this section shall be subject to the penalties set forth in § 56-32-116 or, in the alternative, § 56-32-120.
(3) Such rules shall be promulgated in accordance with the Uniform Administrative Procedures Act, compiled in title 4, chapter 5.
(b) If this section conflicts with any applicable federal waiver concerning medical assistance services delivered pursuant to chapter 5, part 1 of this title, then the commissioner of health is directed to seek an appropriate modification or amendment to such waiver to permit the implementation of this section.
(c) This section shall be construed so as to be consistent with the terms of any applicable federal waiver for the provision of medical assistance.
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