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    v1.0.31
    OpenPayerPolicy UpdatesAdministrative/Operational PolicyTennCare Adult Dental Coverage Update | OpenPayer
    Ask Trek AI about this page
    CurrentTennessee Department of Finance and Administration — Division of TennCarePolicy N/A

    Adult Dental Benefits for ECF CHOICES and 1915(c) Waiver Members

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    Governs coordination, authorization, funding, payment, appeals, and budget tracking for dental services for adults enrolled in ECF CHOICES and 1915(c) waiver programs, including participating dental providers and program staff.

    Policy Summary
    PayerTennessee Department of Finance and Administration — Division of TennCare
    PolicyAdult Dental Benefits for ECF CHOICES and 1915(c) Waiver Members
    Policy CodePolicy N/A
    Change TypeAdministrative revision
    Effective DateJan 1, 2023
    Next Review DateN/A
    Key ActionDo not render listed treatments until the treatment plan is approved, the applicable budget is verified, and DBM authorization is released.
    SourceLink
    POLICY UPDATE CHANGES

    Administration of 1915(c) waiver member dental benefits transferred from DDA to the DBM.

    Renaissance became the TennCare dental benefits manager.

    The standard treatment-plan review timeline changes from 14 calendar days to 7 calendar days.

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    7 daysStandard treatment-plan review
    72 hoursUrgent request determination
    WeeklyPaid claims reports to MCOs/DDA
    2Benefit review levels

    Adult and Waiver-Funded Dental Coverage

    Coordination of Adult and waiver-funded dental benefits

    Covered through sequential review of the member-specific treatment plan under the TennCare Adult Dental Benefit and, for services that remain uncovered, the applicable waiver-funded benefit.

    ALL of the following

    • ALL of the following

      • The member is enrolled in ECF CHOICES or a 1915(c) waiver program.
      • The member-specific dental treatment plan is submitted electronically to the Dental Benefits Manager (DBM) for review of medical necessity and coverage requirements under the TennCare Adult Dental Benefit as the primary benefit.

    • If services remain uncovered

      • ALL of the following

        • The services are reviewed for medically necessary ECF CHOICES or 1915(c) waiver-funded coverage as the secondary benefit.
        • The MCO or DDA reviews whether sufficient funds are available in the member's waiver dental budget.
        • If funds are available, the SC/ISC/CM submits an amended Person-Centered Support Plan (PCSP) with the proposed waiver-funded treatment through the MCO/DDA authorization process.
        • Treatment proceeds only after the applicable authorization is approved and the DBM notifies the dental provider to proceed.

      • ALL of the following

        • If waiver funds are unavailable or insufficient, treatment is limited or prioritized within the member's available benefit limit.
        • The member may choose to pay remaining expenses out of pocket.

    • Benefit accounting

      • Services covered by the TennCare Adult Dental Benefit do not count against the member's waiver expenditure or cost cap.
      • Services provided under the waiver benefit rather than the Adult Dental Benefit count against the applicable waiver expenditure or cost cap.

    Dental service limit exceptions

    Services exceeding the member's yearly or three-year dental service budget may be considered through an exception request.

    ALL of the following

    • The member needs dental services in excess of the yearly or three-year dental service budget.
    • The SC, ISC, or CM includes the exception request in the member's PCSP.
    • DDA or the MCO, as applicable, authorizes the exception.
    • After approval, the DBM applies its internal processes to allow the authorized exception.

    Dental services appeals

    Members may appeal dental service denials based on medical necessity.

    ALL of the following

    • A dental service is denied based on medical necessity for a member enrolled in ECF CHOICES or a 1915(c) waiver program.
    • The member may appeal through the standard TennCare Member Medical Appeals process.

    Review and Funding Timeframes

    Standard treatment-plan review
    Current timeframe7 calendar days beginning January 1, 2026
    Previous timeframe14 calendar days
    ExtensionThe timeline may be extended if additional information or additional review time is requested.
    Urgent request determination
    Determination timeframe72 standard hours
    Applies toUrgent requests for both the Adult Dental Benefit and I/DD program dental benefits
    Request requirementThe dentist must indicate to the DBM that an expedited review is requested.

    Provider Workflow and Billing Responsibilities

    Note

    Use an In-Network Dental Provider

    Use an in-network dental provider when possible. The member’s SC, ISC, or CM may assist with finding a provider, and the DBM can help locate a provider for larger needs such as sedation or complex care.

    • The member sees the contracted dental provider for an initial assessment.
    • The DBM may assist with provider selection when specialized care is needed.
    Documentation Required

    Submit the Treatment Plan Electronically

    After assessing the member, the dental provider must develop a member-specific treatment plan and submit it electronically to the DBM through an approved portal or clearinghouse for review of medical necessity and coverage.

    • The review includes the TennCare Adult Dental Benefit as primary coverage and the ECF CHOICES or 1915(c) waiver-funded benefit as secondary coverage.
    • Adult Dental Benefit approvals are sent directly to the provider and are not added to the PCSP.

    Programs, Roles, and Reporting Terms

    ECF CHOICES
    Full nameEmployment and Community First
    Program typeA program providing long-term services and supports to eligible members
    Dental relevanceECF CHOICES members have access to Adult Dental Benefits and additional waiver-funded dental benefits.
    1915(c) waiver programs
    Program descriptionIntellectual and developmental disabilities waiver programs administered as 1915(c) waivers
    AbbreviationI/DD Programs
    Dental relevance
    Policy Summary
    PayerTennessee Department of Finance and Administration — Division of TennCare
    PolicyAdult Dental Benefits for ECF CHOICES and 1915(c) Waiver Members
    Policy CodePolicy N/A
    Change TypeAdministrative revision
    Effective DateJan 1, 2023
    Next Review DateN/A
    Key ActionDo not render listed treatments until the treatment plan is approved, the applicable budget is verified, and DBM authorization is released.
    SourceLink
    On This Page
    Adult and Waiver-Funded Dental CoverageReview and Funding TimeframesProvider Workflow and Billing ResponsibilitiesPrograms, Roles, and Reporting Terms
    MCO/DDA funding response
    Response timeframeWithin 7 calendar days
    Available fundsThe MCO/DDA notifies the ISC/CM/SC to submit a PCSP amendment for waiver-funded dental services.
    Insufficient or partial fundsThe MCO/DDA notifies the DBM through the Dental Authorization Report when funds are unavailable or only partially cover the treatment plan.

    Unsupported block type: prior_auth

    Documentation Required

    Coordinate Waiver-Funded Services

    Cooperate with the DBM, MCO/DDA, and the member’s SC, ISC, or CM when services are evaluated under the waiver benefit. If waiver-funded services are approved and funds are available, the SC/ISC/CM submits a PCSP amendment and the MCO/DDA reviews and approves it before notifying the DBM through the Dental Authorization Report.

    • The MCO/DDA reviews approved waiver-funded services for budgetary approval and notifies the DBM of the outcome through the Dental Authorization Report.
    • The SC/ISC/CM notifies the member of approval and helps ensure prompt scheduling.
    • Waiver-funded services—not services covered by the Adult Dental Benefit—count against the member’s expenditure or cost cap.
    • Beginning January 1, 2026, applicable MCO/DDA notification and review steps use a 7-calendar-day timeframe.

    Unsupported block type: prior_auth

    Billing Rule

    Submit the Dental Claim After the Visit

    After the visit, submit a dental claim to the DBM through the dental provider’s billing portal or clearinghouse. The claim must detail the procedure codes and date of service for both Adult Dental Benefit and waiver-funded dental services.

    • The DBM issues payment after receiving and approving the claim.
    • The DBM sends a weekly Paid Claims Report electronically to the MCO/DDA for expenditure or cost-cap tracking.

    Unsupported block type: info

    Unsupported block type: info

    1915(c) waiver members have access to Adult Dental Benefits and additional waiver-funded dental benefits.
    DBM
    Full nameDental Benefits Manager
    Primary responsibilityAdministration and review of TennCare Adult Dental Benefits
    Waiver responsibilityFor 1915(c) members, administration and review of waiver dental benefits; effective November 1, 2025, the DBM assumed administration of all 1915(c) member dental benefits.
    SC/ISC/CM
    Full termsSupport Coordinator, Independent Support Coordinator, or Case Manager
    Member supportAssists with finding an in-network dental provider, member notification, and prompt scheduling of treatment appointments.
    Waiver coordinationAssists with PCSP amendments for waiver-funded dental services.
    PCSP
    Full namePerson-Centered Support Plan
    UseUsed for applicable waiver-funded services and amendments
    Dental applicationAn amended PCSP is submitted with proposed waiver-funded dental treatment when waiver funds are available.
    Dental Authorization Report / Paid Claims Report
    Dental Authorization ReportElectronic report used to communicate waiver service determinations between the DBM and MCO/DDA.
    Paid Claims ReportElectronic report used to communicate paid claims between the DBM and MCO/DDA.
    Operational useThe DBM sends Paid Claims Reports weekly, and the MCO/DDA uses them to track the member's expenditure or cost cap.