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