Tenn. Comp. R. & Regs. 1200-11-03-.02

Current through December 10, 2024

Section 1200-11-03-.02 - DEFINITIONS

Unless otherwise specifically indicated by the context, for the purpose of these rules and regulations, the terms used herein are defined as follows.

(1) "Assistive technology/augmentative communication device" means any device or equipment that may promote independence and communication skills for children unable to utilize typical methods for independence.

(2) "Care Coordination" means case management services promoting the effective and efficient organization and utilization of resources to assure access to necessary comprehensive services for children with special healthcare needs and their families. Care coordinators assist families with services such as third party payor billing, filing appeals when third party payors deny payment, and seeking prior approval from third party payors for covered services.

(3) "Child" or "children" means a person or persons under the age of twenty-one (21) years.

(4) "Child with a physical disability" means a child under the age of twenty-one (21) who shall be deemed to have a physical disability by any reason, whether congenital or acquired as a result of accident or disease, which requires medical, surgical, dental or rehabilitation treatment, who is or may be totally or partially incapacitated for the receipt of a normal education or for self-support. This definition shall not include those children whose sole diagnosis is blindness or deafness; nor shall this definition include children who are diagnosed as psychotic. This definition does not prohibit CSS from accepting for treatment children with acute conditions such as, but not necessarily limited to, fractures, burns, and osteomyelitis.

(5) "Commissioner" means the Commissioner of the Tennessee Department of Health or the Commissioner's designee.

(6) "Covered Services" means medical, surgical, and rehabilitative treatment for eligible diagnoses, including the services necessary in order for a child to follow a prescribed treatment plan for an eligible diagnosis.

(7) "Department" means the Tennessee Department of Health.

(8) "Diagnostic evaluation" means physical examinations, medical procedures, laboratory tests, or other procedures deemed necessary for diagnosis.

(9) "Drugs, devices and supplies" means medications, devices and supplies necessary for treatment related to an eligible diagnosis.

(10) "Durable medical equipment" means equipment that can withstand repeated use, is primarily and customarily used to serve a medical purpose, generally is not useful to a person in the absence of illness or injury, and is appropriate for use in the home, including orthotics, prosthetics, and communication aid devices.

(11) "Elective Hospital Admission" means any hospital admission for diagnoses or treatments not immediately necessary to save the patient's life or prevent impending harm.

(12) "Eligible Diagnosis" means a health-related impairment, described in T.C.A. § 68-12-102 and diagnosed by a provider, which may hinder achievement of normal growth and development.

(13) "Hospitalization" means any overnight stay in a hospital which is:

(a) Capable of providing the type of service(s) needed by the child; and

(b) Licensed pursuant to applicable regulations and/or statutes.

(14) "Inpatient hospitalization services" means medical and surgical services (including screening, diagnostic evaluation, therapeutic, corrective, preventive, and palliative services) and facility usage charges (including room and board) provided during hospitalization in a licensed hospital.

(15) "Orthodontic/dental treatment" means medical, surgical, and rehabilitative treatment for eligible cranio-facial (including cleft lip and cleft palate) and cranial diagnoses.

(16) "Outpatient hospitalization services" means medical and surgical services (including screening, diagnostic evaluation, therapeutic, corrective, preventive, and palliative services) and facility usage charges (including temporary room and board) provided as an outpatient service by a licensed hospital or hospital-based Ambulatory Surgical Treatment Center.

(17) "Outpatient clinic services" means diagnoses or treatment services delivered by a licensed health care provider in a facility other than a hospital setting.

(18) "Provider" means a healthcare provider which is a person, persons, or facility licensed pursuant to T.C.A. Titles 63 or 68 to provide healthcare services in Tennessee, or, if the services are being provided in another state, licensed pursuant to the licensing laws of that state.

(19) "Rehabilitation" means services required to assist the individual to achieve or maintain independence. Rehabilitative services may include physical, speech/language, nutritional/feeding, and occupational therapies.

(20) "Resident of Tennessee" means a person who has established a bona fide residence in Tennessee. The test for such residence is (1) an intention to stay indefinitely in a place, joined with (2) some objective indication consistent with that intent, e. g., enrollment of a child in school.

(21) "Support services" means activities that may be necessary to assist the individual or family to access medically necessary and/or recommended care to participate in the activities of daily living.

(22) "Third party payor" means a party, other than the recipient of healthcare, who pays for healthcare. Third party payors include private insurance and the following resources:

(a) The Patient Protection and Affordable Care Act, which is the health-related portion of the Health Care and Education Reconciliation Act of 2010.

(b) Children's Health Insurance Program (CHIP), which is a health insurance program mandated by Title XXI of the Social Security Act that is jointly financed by Federal and State governments and administered by the States. CHIP was previously known as the State Children's Health Insurance Program (SCHIP). Tennessee's CHIP includes the CoverKids program.

(c) CoverRX, which is a program that offers affordable prescription drugs to persons ages nineteen (19) years and older who lack pharmacy coverage.

(d) TennCare, which is the State of Tennessee Medicaid Waiver program that replaced the State's Medicaid program. The TennCare Bureau contracts with managed care organizations (MCOs) to provide a network of providers to serve TennCare enrolled individuals.

(23) "Title V Children with Special Health Care Needs (CSHCN)" means the section of the Title V Maternal and Child Health CSHCN Block Grant that supports the program.

(24) "Vendor or supplier" means authorized person, persons, or facilities approved by the State of Tennessee to provide services in conjunction with established Department of Health and Department of Finance and Administration guidelines.

Tenn. Comp. R. & Regs. 1200-11-03-.02

Original rule filed April 12, 1979; effective May 28, 1979. Repeal and new rule filed December 30, 1983; effective January 29, 1984. Amendment filed May 29, 1990; effective July 13, 1990. Amendment filed December 7, 1998; effective April 30, 1999. Repeal and new rule filed March 21, 2000; effective July 28, 2000. Repeal and new rule filed October 9, 2002; effective December 23, 2002. Amendment filed May 27, 2005; effective September 28, 2005. Repeal and new rules filed September 6, 2016; effective 12/5/2016.

Authority: T.C.A. §§ 4-5-202, 68-1-103, 68-12-101 et seq, and 42 U.S.C. § 701(b).