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Aged, Blind and Disabled Manual Section: Institutional Medicaid Policy Manual Number: 125.020 Chapter: Post-Eligibility Treatment of Income

July 1, 2026 Division of TennCare 15 c. To contract with a dentist licensed in the State of Tennessee who is a Medicare/Medicaid provider. A licensed dentist must perform all services. The dentist’s name and provider number must be entered on the IME request form prior to submitting the bill to TennCare. d. To create and supply all new forms that are submitted from the mobile dental service provider and the LTCF. The facility should ensure that a copy of these forms is kept on file in the patient records at the facility, along with proof that the services were provided by a licensed dentist. 2. These are the requirements for TennCare Member Services: a. Prior to authorizing a deduction for any IME received from a mobile dental services provider, the Eligibility Specialist must view and document in the data base that the consent form, the IME request form, and the verifications of service form have been provided. b. Any services related to the provision of dentures deemed medically necessary must be thoroughly documented in the electronic case record. Process the IME request within thirty (30) days after receipt. c. Once the bills have been processed, Tenncare must notify the responsible party and the LTCF of any action taken to approve or deny the expense as an IME deduction. These expenses will be deducted from the patient’s total income. This will reduce the patient liability. Note: Payment can only be made from the patient liability amount, not from the patient’s trust account or the PNA. If the patient liability is already zero, then payment cannot be allowed. v. Information Needed with Incurred Medical Expense (IME) Submission The Incurred Medical Expense (IME) submission must include the following information: 1. A verification of service/item received, 2. Consent for receipt of service/item, 3. Information relating to medical necessity, and 4. Other identifiers relating to the IME, including the provider number and a description of the service/item received. j. Incurred Medical Expenses Carry Forward Amount When the total of incurred medical expenses (and health insurance premiums) is greater than the individual’s total income less PNA, mandatory expenses, CSIMA and DIMA deductions for the month, deduct only the amount equal to the available income. Incurred medical expenses in excess of the individual’s total available income are carried over into the next month as an IME