10 PROVIDERS

(1) Payment in full. (a) All CoverKids providers, as defined in this Chapter, must accept as payment in full for provision of covered services to a CoverKids enrollee, the amount paid by the MCO, DBM, or PPA, plus any copayment required by the CoverKids program to be paid by the individual. (b) Any non-CoverKids providers who furnish CoverKids covered services by authorization from the MCO, DBM, or PPA must accept as payment in full for provision of covered services to CoverKids enrollees the amounts paid by the MCO, DBM, or PPA plus any copayment required by the CoverKids program to be paid by the individual. (c) CoverKids will not pay for non-emergency services furnished by non-CoverKids providers unless these services are authorized by the MCO, DBM, or PPA. Any non- CoverKids provider who furnishes CoverKids Program covered non-emergency services to a CoverKids enrollee without authorization from the MCO, DBM, or PPA does so at his own risk. He may not bill the patient for such services except as provided in Paragraph (3). (2) Non-CoverKids Providers. (a) When the MCO, DBM, or PPA authorizes a service to be rendered by a non-CoverKids provider, payment to the provider shall be no less than 80% of the lowest rate paid by the MCO, DBM, or PPA to equivalent participating CoverKids network providers for the same service, consistent with the methodology contained in Rule 1200-13-13-.08(2)(a). (b) Covered medically necessary outpatient emergency services, when provided to CoverKids enrollees by non-CoverKids network hospitals, shall be reimbursed at 74% of the 2006 Medicare rates for the services, consistent with the methodology contained in Rule 1200-13-13-.08(2)(b). Emergency care to enrollees shall not require preauthorization. (c) Covered medically necessary inpatient hospital admissions required as the result of emergency outpatient services, when provided to CoverKids enrollees by non- CoverKids network hospitals, shall be reimbursed at 57% of the 2008 Medicare DRG rates (excluding Medical Education and Disproportionate Share components) determined according to 42 CFR § 412 for the services, consistent with the methodology contained in Rule 1200-13-13-.08(2)(c). Such an inpatient stay will continue until no longer medically necessary or until the patient can be safely transported to a network hospital, whichever comes first. (3) Participation in the CoverKids program will be limited to providers who: (a) Accept, as payment in full, the amounts paid by the MCO, DBM, or PPA, including copays from the enrollee, or the amounts paid in lieu of the MCO, DBM, or PPA by a third party (Medicare, insurance, etc.); (b) Maintain Tennessee, or the state in which they practice, medical licenses and/or certifications as required by their practice, or licensure by the Tennessee Department of Mental Health and Substance Abuse Services, if appropriate; (c) Are not under a federal Drug Enforcement Agency (DEA) restriction of their prescribing and/or dispensing certification for scheduled drugs (relative to physicians, osteopaths, dentists and pharmacists); (d) Agree to maintain and provide access to the Division of TennCare and/or its agent all CoverKids enrollee medical records for ten (10) years from the date of service or upon written authorization from TennCare following an audit, whichever is shorter; (e) Provide medical assistance at or above recognized standards of practice; and (f) Comply with all contractual terms between the provider and the MCO, DBM, or PPA (as appropriate) and CoverKids policies as outlined in federal and state rules and regulations and CoverKids provider manuals and bulletins. (g) Failure to comply with any of the above provisions (a) through (f) may subject a provider to the following actions: 1. The provider may be subject to stringent review/audit procedures, which may include clinical evaluation of services and a prepayment requirement for documentation and justification for each claim. 2. The Division of TennCare may withhold or recover payments to an MCO, DBM, or PPA in cases of provider fraud, willful misrepresentation, or flagrant noncompliance with contractual requirements and/or CoverKids policies. 3. The Division of TennCare may refuse to approve or may suspend provider participation with a provider if any person who has an ownership or controlling interest in the provider, or who is an agent or managing employee of the provider, has been convicted of a criminal offense related to that person’s involvement in any program established under Medicare, Medicaid or the US Title XX Services Program. 4. The Division of TennCare may refuse to approve or may suspend provider participation if it determines that the provider did not fully and accurately make any disclosure of any person who has ownership or controlling interest in the provider, or is an agent or managing employee of the provider and has been convicted of a criminal offense related to that person’s involvement in any program under Medicare, Medicaid or the US Title XX Services Program since the inception of these programs. 5. The Division of TennCare shall refuse to approve or shall suspend provider participation if the appropriate State Board of Licensing or Certification fails to license or certify the provider at any time for any reason or suspends or revokes a license or certification. 6. The Division of TennCare shall refuse to approve or shall suspend provider participation upon notification by the US Office of Inspector General Department of Health and Human Services that the provider is not eligible under Medicare, Medicaid, or CHIP for federal financial participation. 7. The Division of TennCare may recover from an MCO, DBM, or PPA any payments made by an enrollee and/or his family for a covered service, in total or in part, except as permitted. If a provider knowingly bills an enrollee and/or his family for a covered service, in total or in part, except as permitted, the Division of TennCare may terminate the provider’s participation in CoverKids. (4) Solicitations and Referrals (a) MCOs, DBMs, PPAs, and providers shall not solicit CoverKids enrollees by any method offering as enticements other goods and services (free or otherwise) for the opportunity of providing the enrollee with CoverKids-covered services that are not medically necessary and/or that overutilize the CoverKids program. (b) An MCO, DBM, or PPA may request a waiver from this restriction in writing to the Division of TennCare. TennCare shall determine the value of a waiver request based upon the medical necessity and need for the solicitation. The MCO, DBM, or PPA may implement the solicitation only upon receipt of a written waiver approval from TennCare. This waiver is not transferable and may be canceled by TennCare upon written notice. (c) CoverKids payments for services related to a non-waivered solicitation enticement shall be considered by the Division of TennCare as a non-covered service and recouped. Neither the MCO, DBM, PPA nor the provider may bill the enrollee for non-covered services recouped under this authority. (d) A provider shall not offer or receive remuneration in any form related to the volume or value of referrals made or received from or to another provider. (5) Providers may seek payment from a CoverKids enrollee only under the following circumstances. These circumstances include situations where the enrollee may choose to seek a specific covered service from a non-CoverKids provider. (a) If the services are not covered by the CoverKids program and, prior to providing the services, the provider informed the enrollee that the services were not covered. (b) If the services are not covered because they are in excess of an enrollee’s benefit limit and one of the following circumstances applies: 1. The provider has information in her own records to support the fact that the enrollee has reached his benefit limit for the particular service being requested and, prior to providing the service, informs the enrollee that the service is not covered and will not be paid for by CoverKids. This information may include: (i) A previous written denial of a claim on the basis that the service was in excess of the enrollee’s benefit limit for a service within the same benefit category as the service being requested, if the time period applicable to the benefit limit is still in effect; (ii) That the provider had personally provided services to the enrollee in excess of his benefit limit within the same benefit category as the service being requested, if the time period applicable to that benefit period is still in effect; or (iii) The enrollee’s MCO, DBM, or PPA has provided confirmation to the provider that the enrollee has reached his benefit limit for the applicable service. 2. The provider submits a claim for service to the MCO, DBM, or PPA and receives a written denial of that claim on the basis that the service exceeds the enrollee’s benefit limit. After informing the enrollee and within the remainder of the period applicable to that benefit limit, the provider may bill the enrollee for services within that same exhausted benefit category without having to submit claims for those subsequent services for repeated MCO, DBM, or PPA denial. If the provider informed the enrollee prior to providing the service for which the claim was denied that the service would exceed the enrollee’s benefit limit and would not be paid for by CoverKids, the provider may bill the enrollee for that service. 3. The provider had previously taken the steps in Parts 1. or 2. above and determined that the enrollee had reached his benefit limit for the particular service being requested, if the time period applicable to the benefit limit is still in effect, and informs the enrollee, prior to providing the service, that the service is not covered and will not be paid for by CoverKids. (c) If the services are covered only with prior authorization and prior authorization has been requested but denied, or is requested and a specified lesser level of care is approved, and the provider has given prior notice to the enrollee that the services are not covered, the enrollee may elect to receive those services for which prior authorization has been denied or which exceed the authorized level of care and be billed by the provider for such services. (6) Providers may not seek payment from a CoverKids enrollee under the following conditions: (a) The provider knew or should have known about the patient’s CoverKids enrollment prior to providing services. (b) The claim submitted to the MCO, DBM, or PPA for payment was denied due to provider billing error or a CoverKids claim processing error. (c) The provider accepted CoverKids assignment on a claim and it is determined that another payer paid an amount equal to or greater than the CoverKids allowable amount. (d) The provider failed to comply with CoverKids policies and procedures or provided a service which lacks medical necessity or justification. (e) The provider failed to submit or resubmit claims for payment within the time periods required by the MCO, DBM, PPA, or CoverKids. (f) The provider failed to inform the enrollee prior to providing a service not covered by CoverKids that the service was not covered and the enrollee may be responsible for the cost of the service. Services which are non-covered by virtue of exceeding limitations are exempt from this requirement if the provider has complied with Paragraph (3) above. (g) The enrollee failed to keep a scheduled appointment(s). (7) Providers may seek payment from a person whose CoverKids eligibility is pending at the time services are provided if the provider informs the person that CoverKids assignment will not be accepted whether or not eligibility is established retroactively. (8) Providers may seek payment from a person whose CoverKids eligibility is pending at the time services are provided. Providers may bill such persons at the provider’s usual and customary rate for the services rendered. However, all monies collected for CoverKids-covered services rendered during a period of CoverKids eligibility must be refunded when a claim is submitted to CoverKids if the provider agreed to accept CoverKids assignment once retroactive CoverKids eligibility was established. (9) Providers of inpatient hospital services, outpatient hospital services, skilled nursing facility services, independent laboratory and x-ray services, hospice services, and home health agencies must be approved for Title XVIII Medicare in order to be certified as providers under the CoverKids program; in the case of hospitals, the hospital must meet state licensure requirements and be approved by the Division of TennCare as an acute care hospital as of the date of enrollment in CoverKids. Children’s hospitals and state mental hospitals may participate in CoverKids without having been Medicare approved; however, the hospital must be approved by the Joint Commission for Accreditation of Health Care Organizations as a condition of participation. (10) Pharmacy providers may not waive pharmacy copayments for CoverKids enrollees as a means of attracting business to their establishments. This does not prohibit a pharmacy from exercising professional judgment in cases where an enrollee may have a temporary or acute need for a prescribed drug, but is unable, at that moment, to pay the required copayment. (11) All claims must be filed with an MCO, DBM, or PPA and must be submitted in accordance with the requirements and timeframes set forth in the MCO, DBM, or PPA’s contract. 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. Rule was originally numbered 1200-13-21-.08 but was renumbered 1200-13-21-.10 with the introduction of new rules 1200- 13-21-.04 and 1200-13-01-.06 filed January 11, 2021; effective April 11, 2021. Amendments filed January 11, 2021; effective April 11, 2021.