Provider Requirements
TennCare requires that TENNderCare screenings be performed according to the standards of the American Academy of Pediatrics including:
Screenings do not have to meet the prerequisite of “medically necessary” for MCO coverage and should include referrals for dental check ups by age three, or earlier if needed.
Comprehensive health and developmental history includes:
- Physical
- Behavioral/Developmental
- Dental
- Compare child's physical growth against what is considered normal for child's age
- Lead Blood test should be performed at 12 months and 24 months. Assessed at each visit beginning at 6 months
- Age appropriate and current status of shots in accordance with the American Academy of Pediatrics
- Includes an age-appropriate hearing assessment. Tools used for hearing screenings shall be consistent with the Screening Guidelines
- Includes age- appropriate vision assessment. Tools used for screenings shall be consistent with the Screening Guidelines
- Anticipatory Guidance (car seat safety, sex education, smoking, etc.)
- Counseling parents and child, regarding child's development
- Healthy lifestyle, accident, and disease prevention
Additional TENNderCARE Requirements
Dental Services - At a minimum must include relief of pain and infections, restoration of teeth and maintenance of dental health. Dental services may not be limited to emergency services. Although an oral screening may be part of the physical examination, it does not substitute for examination through direct referral to a dentist. A direct dental referral is required for every child beginning at the age of three, or earlier if determined to be medically necessary.
Diagnosis- When a screening examination indicates the need for further evaluation of an individual’s health, diagnostic services should be provided. The referral should be made without delay and followed up to confirm that the enrollee receives a complete diagnostic evaluation. TennCare MCOs and BHOs provide diagnostic evaluations.
Treatment- Health care must be made available for treatment or other measures to correct or ameliorate defects and physical and mental illnesses or conditions discovered by the screening services. Both the MCO and the BHO provide treatment.
Providers who perform TENNderCare screens may identify potential health, behavioral or developmental problems. They are responsible for making referrals to other MCO or BHO providers for further testing or treatment. While there is no requirement that periodic or interperiodic screenings meet the definition of “medically necessary”, additional testing and treatment services must be medically necessary. Screening follow-ups are just as important as the initial screenings.
Lead Toxicity Screening- All children are considered at risk and must be screened for lead poisoning. TennCare requires the use of the blood lead test when screening children for lead poisoning. Physicians should use each office visit as an opportunity for anticipatory guidance and risk assessment for lead poisoning. All children from 6 to 72 months of age are considered at risk and must be screened. Any additional diagnostic and treatment services determined to be medically necessary must also be provided to a child diagnosed with an elevated blood lead level.
Interperiodic Screens- In addition to covering scheduled periodic check ups, TENNderCare covers visits to a health care provider, when needed, outside of the periodicity schedule to determine whether a child has a condition that needs further care. These types of screens are called “interperioidic screens”. Persons outside the health care system, such as a teacher or parent, can determine the need for an interperiodic screen. Screenings shall be performed at distinct intervals and in accordance with the American Academy of Pediatrics Recommendations for Pediatric Health Care.
Outreach and Informing Activities- Outreach and informing activities are a requirement under TENNderCare regulations. All MCOs should provide eligible individuals and/or their families basic information on what services are available under the TENNderCare (EPSDT) program, the benefits of preventive health care, where the services are available, how to obtain them and that transportation and scheduling assistance are available.
