Tenn. Comp. R. & Regs. 1200-13-18-.01 - SCOPE AND AUTHORITY

(1) An approved provider of TennCare services may appeal the following administrative actions:

(a) An administrative action for recovery against a person other than an enrollee, recipient or applicant brought by the Bureau of TennCare upon written request of the Attorney General pursuant to the Tennessee Medicaid False Claims Act;

(b) An action proposed or taken by the Bureau of TennCare or its audit contractor to recover, recoup or withhold payment from a provider, as a result of any audit performed by or on behalf of the Centers for Medicare and Medicaid Services or the Bureau pursuant to state or federal law;

(c) A Bureau of TennCare determination to suspend payments to a provider due to a credible allegation of fraud for which an investigation is pending;

(d) A denial of eligibility for or a determination of the amount of an incentive payment pursuant to the federal Medicaid Electronic Health Record Incentive Program (EHR-IP); or,

(e) Termination of an approved provider's Tennessee Medicaid Provider Number by the Bureau, except when federal law mandates exclusion of the provider.

(2) A provider of services may not appeal the following administrative actions:

(a) An MCC's refusal to contract with the provider;

(b) A decision by the Bureau to decline coverage of prescriptions not written by a provider with prescribing authority; or,

(c) Termination or exclusion from the Program as required by federal law.

(3) In order to exercise the right to a hearing, a provider must submit his appeal and request for a hearing in writing to the Bureau. The notice of the Bureau action shall contain specific instructions concerning the right to appeal and the address for filing an appeal.

(4) Any request for an appeal must be received at the address contained in the notice of action no later than 35 days following the date of the notice.

(5) Provider appeals shall be conducted as contested case hearings by the Tennessee Department of State, Administrative Procedures Division, pursuant to the Tennessee Uniform Administrative Procedures Act (APA).

(6) The Uniform Rules of Procedure for Hearing Contested Cases Before State Administrative Agencies, Chapter 1360-04-01, promulgated under the APA, are adopted by the Bureau and incorporated by reference herein. The Uniform Rules shall govern the conduct of a provider appeal except where a specific contrary provision is adopted by the Bureau in this Chapter.

(7) For purposes of issuing an initial order, a contested case hearing shall be conducted by an administrative judge hearing the case alone.

Notes

Tenn. Comp. R. & Regs. 1200-13-18-.01

Emergency rule filed February 18, 2011; effective through August 17, 2011. Original rule filed May 18, 2011; effective August 16, 2011.

Statutory Authority: T.C.A. §§ 4-5-202, 71-5-105 and 71-5-109.