02 DEFINITIONS

(1) Covered services. Benefits and services listed in this Chapter and provided for enrollees in the CoverKids program by an MCO, DBM, PPA or other entity under contract with the Division of TennCare. (2) CoverKids. The program created by T.C.A. §§ 71-3-1101, et seq., its authorized employees and agents, as the context of this Chapter requires, and administered through the Division of TennCare, which provides health coverage for children under nineteen (19) years of age and pregnant women, who do not have health insurance and do not qualify for TennCare. (3) CoverKids network. A group of health care providers that have entered into contracts with an MCO, DBM, PPA or other entity under contract with the Division of TennCare to furnish covered services to CoverKids enrollees. (4) CoverKids Pregnant Women. The part of the CoverKids program that provides coverage for the unborn children of pregnant women with no source of health coverage who meet the CoverKids eligibility requirements. (5) CoverKids provider. A health care provider who accepts as payment in full for furnishing benefits to a CoverKids enrollee the amounts paid pursuant to an approved agreement with a TennCare contractor. Such payment may include copayments from the enrollee or the enrollee’s responsible party. A CoverKids provider, including an Out-of-State Emergency Provider as defined in Rule 1200-13-13-.01, must be enrolled with TennCare and must abide by all CoverKids rules and regulations, including requirements regarding provider billing of patients as found in Rule .10. CoverKids providers must be appropriately licensed for the services they deliver and must not be providers who have been excluded from participation in the federal Medicare, Medicaid or CHIP programs. (6) Days. Calendar days, not business days. (7) Dental Benefits Manager (DBM). The entity responsible for the administrative services associated with providing covered dental services, preventive, routine and orthodontic, to CoverKids enrollees. (8) Emergency services. Includes emergency medical, emergency mental health and substance abuse emergency treatment services, furnished by a provider qualified to furnish the services, needed to evaluate, treat, or stabilize an emergency medical condition manifested by the sudden and unexpected onset of acute symptoms of sufficient severity, including severe pain, that a prudent layperson with an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in: (a) Placing the person’s (or with respect to a pregnant woman, her unborn child’s) health in serious jeopardy; (b) Serious impairment to bodily functions; or (c) Serious dysfunction of any bodily organ or part. (9) Managed Care Organization (MCO). An appropriately licensed Health Maintenance Organization (HMO) approved by the Division of TennCare as capable of providing medical, behavioral, and long-term care services which has signed a Contractor Risk Agreement, as defined in 1200-13-13-.01, with the Division of TennCare and operates a provider network to provide covered services to CoverKids enrollees. (10) Medically necessary. A medical item or service which meets all the following criteria: (a) Recommended by a licensed physician who is treating the enrollee or other licensed healthcare provider practicing within his scope of licensure who is treating the enrollee; (b) Required in order to diagnose or treat an enrollee’s medical condition; (c) Safe and effective; (d) The least costly alternative course of diagnosis or treatment that is adequate for the medical condition of the enrollee; and (e) Not experimental or investigational. (11) Non-CoverKids provider. A health care provider of non-emergency services that does not participate in the network of a TennCare-contracted MCO, DBM, or PPA or other entity contracted to administer CoverKids benefits. (12) Parent. A natural or adoptive father or mother of a minor child; or, a guardian as defined by T.C.A. § 34-1-101, subject to court orders entered or recognized by the courts of the state of Tennessee. (13) Pharmacy Plan Administrator (PPA). The entity responsible for the administrative services associated with providing pharmaceutical related covered services to CoverKids enrollees. Authority: T.C.A. §§ 4-5-202, 4-5-203, 4-5-204, 71-3-1106, and 71-3-1110; 42 U.S.C. §§ 1397aa, et seq.; and the Tennessee Title XXI Children’s Health Insurance Program State Plan. Administrative History: Original rules filed November 28, 2018; effective February 26, 2018. Amendments filed January 11, 2021; effective April 11, 2021.