When Written Notice
1. A written notice shall be
given to an enrollee by his/her MCC of any adverse benefit
2. A written notice
shall be given to an enrollee of any MCC-initiated reduction, termination or
suspension of inpatient hospital care.
3. A written notice shall be given to an
enrollee of any provider-initiated reduction, termination or
4. Appropriate notice
shall be given to an enrollee by the State or MCC when a claim for service or
reimbursement is denied because an enrollee has exceeded a benefit limit. Such
notice shall not be subject to the requirements of rule 1200-13-14-.11(1)(c) 1.
During the applicable time period for each benefit limit, such notice shall
only be provided the first time a claim is denied because an enrollee has
exceeded a benefit limit. The State or MCC will not be required to provide any
notice when an enrollee is approaching or reaches a benefit limit.
Appropriate notice shall be given to an
enrollee by a provider when an enrollee exceeds a non-pharmacy benefit limit in
the following circumstances:
(i) The provider
denies the request for a non-pharmacy service because an enrollee has exceeded
the applicable benefit limit; or
The provider informs an enrollee that
the non-pharmacy service will not be covered by TennCare because he/she has
exceeded the applicable benefit limit and the enrollee chooses not to receive
During the applicable time period for each non-pharmacy
benefit limit, providers shall only be required to issue this notice the first
time an enrollee does not receive a non-pharmacy service from the provider
because he/she has exceeded the applicable benefit limit. Such notice shall not
be subject to the requirements of rule 1200-13-14-.11(1)(c) 1. Providers will
not be required to issue any notice when an enrollee is approaching or reaches
a non-pharmacy benefit limit.
Timing of Written Notice.
Written notice of MCC-initiated reduction,
termination or suspension of medical assistance must be provided to an enrollee
within the time frames required by
42 C.F.R. §§
(usually ten (10) days in advance). However, in instances of MCC-initiated
reduction, termination or suspension of inpatient hospital treatment, the
notice may be provided to an enrollee the same day of the proposed action.
Where applicable and not in conflict with this rule, the exceptions set out at
42 C.F.R. §§
permit or require reduction of the time frames within which advance notice must
An MCC must notify
an enrollee of its decision in response to a request by or on behalf of an
enrollee for prior authorization for medical or related services as set out in
42 C.F.R. §
3. Written notice of delay of covered medical
assistance must be provided to an enrollee immediately upon an MCC's receipt of
information leading it to expect that such delay will occur.
Written notice of provider-initiated
reduction, termination or suspension of services must be provided to an
enrollee in compliance with
42 C.F.R. §§
5. Written notice is deemed to be provided to
an enrollee upon deposit with the US Postal Service or other commercial mail
carrier, or upon hand-delivery to an enrollee or his/her
Whenever this rule
requires that a TennCare enrollee receive written notice of an adverse benefit
determination, the notice must be readable and must comply with the
42 C.F.R. §§
2. Remedying of Notice. If a notice of
adverse benefit determination provided to an enrollee does not meet the notice
content requirements of rule 1200-13-14-.11(1)(c) 1., TennCare or the MCC may
cure any such deficiencies by providing one corrected notice to enrollees. If a
corrected notice is provided to an enrollee, the reviewing authority shall
consider only the factual reasons and legal authorities cited in the corrected
notice, except that additional evidence beneficial to the enrollee may be
considered on appeal.
Appeal Rights of Enrollees. Enrollees
have the following rights:
(a) To appeal
adverse actions benefit determinations.
(b) An enrollee's request for appeal,
including oral or written expressions by the enrollee, or on his behalf, of
dissatisfaction or disagreement with adverse benefit determinations that have
been made or are proposed to be made, may not be denied.
To have the appeal rights that are
prescribed by 42 C.F.R. Part 431
, Subpart E and Tennessee Code Annotated
(d) To be allowed sixty
(60) days from the date on the written notice or, if no notice is provided,
from the time the enrollee becomes aware of an adverse benefit determination,
to appeal any adverse benefit determination. To file a Request for
Reimbursement for expenses incurred between the effective eligibility date and
the date that notice of eligibility is provided, the enrollee must request
reimbursement and provide complete information to TennCare, as prescribed by
Rule.01, within sixty (60) days from the date of the written notification of
the effective eligibility date or, if no written notice is provided, within
sixty (60) days from the date the enrollee becomes aware of the effective
eligibility date. For all other Requests for Reimbursement, the enrollee must
request reimbursement and provide complete information, as prescribed by
Rule.01, within sixty (60) days from the date the enrollee paid out of pocket
for covered services.
(e) To appeal
in person, by telephone, or in writing. Reasonable accommodations shall be made
for any person with disabilities who requires assistance with his/her appeal,
such as an appeal by TDD services or other communication device for people with
disabilities. Written requests for appeals made at county TDHS offices shall be
stamped and immediately forwarded to the TennCare Bureau for processing and
entry in the central registry.
For ongoing services, have the right to continuation or reinstatement of
services, pursuant to
42 C.F.R. §§
modified by this rule, pending resolution of the appeal when the enrollee
submits a timely appeal and timely request for COB. When an enrollee is so
entitled to continuation or reinstatement of services, this right may not be
denied for any reason, including:
1. An MCC's
failure to inform an enrollee of the availability of such continued
2. An MCC's failure to
reimburse providers for delivering services pending appeal; or
3. An MCC's failure to provide such services
when timely requested.
(g) To an appeals process. But for initial
reconsideration by an MCC as permitted by this rule, no person who is an
employee, agent or representative of an MCC may participate in deciding the
outcome of a SFH. No state official who was directly involved in the initial
determination of the action in question may participate in deciding the outcome
of an enrollee's appeal.
Special Provisions Relating to Appeals.
(a) Individualized Decisions Required.
Neither the TennCare program nor its MCCs may employ utilization control
guidelines or other quantitative coverage limits, whether explicit or de facto,
unless supported by an individualized determination of medical necessity based
upon the needs of each TennCare enrollee and his or her medical
1. Appeal decisions must be based on an
evaluation of pertinent medical evidence. TennCare and the MCCs shall elicit
from enrollees and their treating providers all pertinent medical records that
support an appeal; and
opinions shall be evaluated pursuant to TennCare Medical Necessity rule
1200-13-16. Reliance upon insurance industry guidelines or utilization control
criteria of general application, without consideration of the individual
enrollee's medical history, does not satisfy this requirement and cannot be
relied upon to support an adverse benefit determination.
(c) Record on Review. When TennCare receives
an appeal from an enrollee regarding an adverse benefit determination, TennCare
is responsible for obtaining from the MCC any and all records or documents
pertaining to the MCC's decision to take the contested action. TennCare shall
correct any violation of this rule that is evident from a review of those
Disputes. When TennCare receives an appeal from an enrollee, TennCare will
dismiss this appeal unless the enrollee has established a valid factual dispute
relating to an adverse benefit determination.
1. Processing of Appeals. TennCare shall
screen all appeals submitted by TennCare enrollees to determine if the
enrollees have presented a valid factual dispute. If TennCare determines that
an enrollee failed to present a valid factual dispute, TennCare will
immediately provide the enrollee with a notice, informing him/her that the
enrollee must provide additional information as identified in the notice. If
the enrollee does not provide this information, the appeal shall be dismissed
without the opportunity for a state fair hearing within ten (10) days of the
date of the notice. If the enrollee adequately responds to this notice,
TennCare shall inform the enrollee that the appeal will proceed to a hearing.
If the enrollee responds but fails to provide adequate information, TennCare
will provide a notice to the enrollee, informing him/her that the appeal is
dismissed without the opportunity for a state fair hearing. If the enrollee
does not respond, the appeal will be dismissed without the opportunity for a
state fair hearing, without further notice to the enrollee.
2. Information Required to Establish Valid
Factual Disputes. In order to establish a valid factual dispute, TennCare
enrollees must provide the following information: Enrollee's name; member SSN
or TennCare ID#; address and phone; identification of the service or item that
is the subject of the adverse benefit determination; and the reason for the
appeal, including any factual error the enrollee believes TennCare or the MCC
has made. For reimbursement and billing appeals, enrollees must also provide
the date the service was provided, the name of the provider, copies of receipts
which prove that the enrollee paid for the services or copies of a bill for the
services, whichever is applicable.
Appeals When Enrollees Lack a
Prescription. When a TennCare enrollee attempts to lodge an appeal for a
benefit for which the enrollee lacks a prescription, TennCare may require the
enrollee to exhaust the following administrative process before an appeal can
1. TennCare will provide appropriate
notice to the enrollee informing him/her that he/she will be required to
complete an administrative process. Such administrative process requires the
enrollee to contact the MCC to make an appointment with a provider to evaluate
the request for the service. The MCC shall be required to make such appointment
for the enrollee within a 3-week period or fortyeight (48) hours for urgent
care from the date the enrollee contacts the MCC. Appeal timeframes will be
tolled during this administrative process.
2. In order for this appeal to continue, the
enrollee shall be required to contact TennCare after attending the appointment
with a physician and demonstrate that he/she remains without a prescription for
the service. If the enrollee fails to contact TennCare within sixty (60) days
from the date of the notice described in subparagraph (e)1., TennCare will
dismiss the appeal without providing an opportunity for a hearing for the
When No Adverse Benefit Determination Has Been Made. Enrollees shall not
possess the right to appeal when no adverse benefit determination has been
made. If enrollees request a hearing in this circumstance, their request shall
be denied by the TennCare bureau without the opportunity for a hearing. Such
circumstances include but are not limited to when enrollees appeal and no
request for services had previously been denied.
Hearing Rights of Enrollees.
(a) TennCare shall inform enrollees of their
state fair hearing rights;
Enrollees shall be entitled to a hearing before a hearing officer that affords
each enrollee the right to:
at the hearing by anyone of his/her choice, including a lawyer;
2. Review information and facts relied on for
the decisions by the MCC and the TennCare Bureau before the hearing;
3. Cross-examine adverse witnesses;
4. Present evidence, including the right to
compel attendance of witnesses at hearings;
5. Review and present information from
his/her medical records;
evidence at the hearing challenging the adverse decision by his/her
7. Ask for an independent
medical opinion, at no expense to the enrollee;
8. Continue or reinstate ongoing services
pending a hearing decision, as specified in this rule;
9. A written decision setting out the hearing
officer's rulings on findings of fact and conclusions of law; and
Resolution, including a hearing before a
hearing officer if the case has not been previously resolved in favor of the
enrollee, pursuant to
42 C.F.R. §
(c) TennCare shall not impair the ability of
an enrollee to appeal an adverse hearing decision by requiring that the
enrollee bear the expense of purchasing a hearing transcript when such purchase
would be a financial hardship for the enrollee.
(d) Parties to an Appeal. Under this rule,
the parties to a state fair hearing are limited to the enrollee and TennCare,
permitted by federal regulations as modified by CMS letter dated June 5, 2017.
The purpose of the hearing is to focus on the enrollee's medical
(e) Consistent with the Code
of Judicial Conduct, hearing officers shall assist pro se enrollees in
developing the factual record and shall have authority to order second medical
opinions at no expense to the enrollee.
Review of Hearing Decisions.
Hearing officers shall promptly issue an
Order of their decision. Any Order delivered orally from the bench in an
expedited hearing by a hearing officer shall be effective immediately as to the
provision or denial of benefits. In accordance with 42 C.F.R. Part 431
E and 42 C.F.R. Part 438
Subpart F, the hearing officer shall enter a written
order as soon as practicable and shall provide the parties with copies of such
Orders. The time for appealing any oral Order shall not begin to run until
entry of the written Order.
TennCare Bureau shall have the opportunity to review all decisions of hearing
officers, in accordance with T.C.A. §§
to determine whether such decisions are contrary to applicable law, regulations
or policy interpretations, which shall include but not be limited to decisions
regarding the defined package of covered benefits, determinations of medical
necessity and decisions based on the application of this chapter and 42 C.F.R.
Subpart E and 42 C.F.R. Part 438
(i) If TennCare modifies or overturns the
decision of the hearing officer, TennCare shall issue a written decision that
will be provided to the enrollee and the hearing officer. TennCare's decision
shall constitute final agency action.
(ii) If TennCare does not modify or overturn
the decision of the hearing officer, the hearing officer's decision shall
constitute final agency action without additional notice to the
(iii) Review of final
agency action shall be available to enrollees pursuant to T.C.A. §
(iv) A hearing officer's decision in an
enrollee's appeal shall not be deemed precedent for future appeals.
Reinstatement of TennCare Services.
42 C.F.R. §§
if required or if the enrollee requests, TennCare services shall continue or be
reinstated until the earlier of dismissal of the appeal through the valid
factual dispute process, enrollee's withdrawal of the appeal, or an initial
hearing decision adverse to the enrollee.
2. In the case of a timely request for
continuation or reinstatement of the TennCare services described in paragraph
(4)(g)1. above, the services shall continue or be reinstated only if and to the
extent prescribed by the enrollee's treating clinician.
Notwithstanding the requirements of this
part, TennCare enrollees are not entitled to continuation or reinstatement of
services pending an appeal related to the following:
(i) When a service is denied because the
enrollee has exceeded the benefit limit applicable to that service;
When a request for prior authorization
is denied for a prescription drug, with the exception of:
(I) Pharmacists shall provide a single
72-hour interim supply in emergency situations for the non-authorized drug
unless such supply would exceed applicable pharmacy benefit limits;
(II) When the drug has been
prescribed on an ongoing basis or with unlimited refills and becomes subject to
prior authorization requirements.
(iii) When coverage of a prescription drug or
service is denied because the requested drug or service is not a category or
class of drugs or services covered by TennCare;
(iv) When coverage for a prescription drug is
denied because the enrollee has been locked into one pharmacy and the enrollee
seeks to fill a prescription at another pharmacy;
(v) When a request for reimbursement is
denied and the enrollee appeals this denial;
(vi) When a physician has failed to prescribe
or order the service or level of service for which continuation or
reinstatement is requested; or
(vii) If TennCare had not paid for the type
and amount of service for which continuation or reinstatement is requested
prior to the appeal.
Release of Enrollee's Medical Records.
(a) When a request is made, by or on behalf
of a TennCare enrollee, for approval of a TennCare service or for an appeal of
an adverse benefit determination, the enrollee is deemed to have consented to
release of his/her relevant medical records to his/her MCC and the TennCare
Bureau for the purposes of acting upon the enrollee's request.
(b) Providers shall promptly provide copies
of an enrollee's medical records to the enrollee's MCC(s) and to the TennCare
Bureau upon being informed by the MCC(s) or TennCare Bureau that the records
have been requested for the purpose of acting upon an enrollee's request for
approval of a TennCare service or an enrollee's appeal of an adverse benefit
(c) An enrollee's
consent to release of his/her medical records may be evidenced by his signature
(or his provider's or authorized representative's signature) upon the
enrollee's initial application for TennCare, upon his TennCare appeal form or
other written request for authorization or appeal, or, in the event of an
appeal by telephone, by a TennCare Bureau employee's signing of an appeal form
on behalf of an enrollee with documentation of consent to do so.
(d) The medical records obtained by MCCs and
the TennCare Bureau under this rule remain confidential. MCCs and the TennCare
Bureau may use and disclose the records only as necessary in their
consideration of the enrollee's request for approval of a TennCare service or
the enrollee's appeal of an adverse benefit determination.
MCCs must act upon a request for prior
authorization as provided in
42 C.F.R. §
(b) MCCs must complete reconsideration of
standard appeals within fourteen (14) calendar days of the request from
TennCare. MCCs must complete reconsideration of expedited appeals within
seventy-two (72) hours of the request for SFH.
All standard and expedited appeals not
previously resolved in favor of the enrollee during reconsideration, shall be
set for hearing before a hearing officer, and shall be resolved pursuant to the
timeframes set forth in
42 C.F.R. §
. In accordance with
42 C.F.R. §
and 42 C.F.R.
, SFH requests which are approved for expedited resolution
and which are not resolved in the enrollee's favor during MCC's
reconsideration, shall be resolved by TennCare within three (3) working days
from the date of the MCC's reconsideration determination. TennCare is not
charged with any delays attributable to the enrollee.
(d) In no circumstance will a directive be
issued by the TennCare Bureau or a hearing officer to provide a service to an
enrollee if, when the appeal is resolved, the service is no longer covered by
TennCare for the enrollee. A directive also will not be issued by the TennCare
Bureau if the service cannot reasonably be provided to the enrollee before the
date when the service is no longer covered by TennCare for the
Relating to Children in State Custody. Children in the custody of the State
have the rights and protections established by 42 C.F.R. Part 431
, Subpart E
regarding TennCare services and benefits.
Tenn. Comp. R. &
Public necessity rule filed July 1, 2002; effective through
December 13, 2002. Original rule filed September 30, 2002; to be effective
December 14, 2002; however, on December 9, 2002, the House Government
Operations Committee of the General Assembly stayed rule 1200-13-14-.11; new
effective date February 12, 2003. Emergency rule filed December 13, 2002;
effective through May 27, 2003. Public necessity rule filed May 5, 2005;
effective through October 17, 2005. Public necessity rule filed July 29, 2005;
effective through January 10, 2006. Amendments filed July 28, 2005; effective
October 11, 2005. Public necessity rule filed December 29, 2005; expired June
12, 2006. On June 13, 2006, affected rules reverted to status on December 28,
2005. Amendments filed October 27, 2005; effective January 10, 2006. However,
Notice of Withdrawal of permanent rule amendments (1)(d)3., (1)(d)4., (4)(g)6.,
(5)(a)5., (5)(e), (5)(f), and (7)(h) filed and effective January 6, 2006 (to
have been effective January 10, 2006). Public necessity rule filed May 17,
2006; effective through October 29, 2006. Amendments filed March 31, 2006;
effective June 14, 2006. Amendment filed August 14, 2006; effective October 28,
2006. Public Necessity rule filed December 1, 2006; effective through May 15,
2007. Amendment filed January 30, 2007; effective April 15, 2007. Amendment
filed March 1, 2007; effective May 15, 2007. Amendment filed September 13,
2007; effective November 27, 2007. Amendment filed August 19, 2008; effective
November 2, 2008. Amendment filed September 30, 2009; effective December 29,
2009. Amendment filed October 26, 2010; effective January 24, 2011. Amendment
filed September 23, 2011; effective December 22, 2011. Amendments filed
September 27, 2013; effective December 26, 2013. Amendments filed September 25,
2017; effective December 24, 2017. Amendments filed July 8, 2021; effective
Authority: T.C.A. §§
42 C.F.R. Part 431 Subpart E; 42 C.F.R. Part 438 Subpart F; and Executive Order