Developmental Disabilities |
Pre-Admission Evaluation (PAE)
The Pre-Admission Review Unit processes Pre-Admission Evaluations (PAE's) to determine medical eligibility for admission to Nursing Homes, Intermediate Care Facilities for people with mental retardation, and to the Home and Community Based Services waiver programs that provide home and community-based services for people with mental retardation in lieu of institutionalized care.
Quality & Utilization Review
The Quality & Utilization Review Unit is responsible for monitoring the quality of care provided by nursing homes and Home and Community Based Service waiver programs. Additionally, the unit monitors utilization in order to contain costs and identify potential fraud.
The unit is also responsible for assuring the health, safety and welfare of enrollees through annual follow-up and focused quality monitoring surveys.
Claims Processing
The Claims Processing Unit performs tasks associated with the processing of claims submitted for services provided to the elderly and disabled, or enrollees with mental retardation and/or developmental disabilities. The HCBS claims are processed by TennCare’s Fiscal Agent. Weekly remittance advice (RA) reports are reviewed by Claims Processing staff to ensure proper payment. Denied claims are individually reviewed for proper resolution. Suspended claims are re-processed by the Fiscal Agent and by Claims Processing staff.
Programs and Policy
The Programs and Policy Unit is responsible for the oversight and coordination of the Home and Community Based Services (HCBS) waiver programs including:
- Preparation and submission of waiver applications
- Waiver amendments
- Reports
- Development of policies
- Procedures
- Rules
- Interpretation of federal and state rules, regulations, and policies.
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