(1) Administrative Judge. An employee or
official of the Office of the Secretary of State who is licensed to practice
law and authorized by law to conduct contested case proceedings.
(2) Administrative Procedures Act (APA). The
Tennessee Uniform Administrative Procedures Act, as amended, codified at T.C.A.
4-5-301, et seq.
(3) Approved Provider. A provider of health
care services who has registered with and been approved by the Bureau and has
been issued a Tennessee Medicaid Provider Number.
(4) Audit. The systematic process of
objectively obtaining and evaluating evidence regarding assertions about
economic actions and events to ascertain the degree of correspondence between
those assertions and established criteria and communicating the results to
interested parties. Audits are conducted in accordance with AICPA (American
Institute of Certified Public Accountants) auditing or attestation engagement
standards. For purposes of this chapter, audits are conducted of health care
provider records, financial information, and statistical data according to
principles of cost reimbursement to determine the reasonableness and allowance
of costs reimbursable under the Program. Statistically valid random sampling is
used to determine actual damages.
(5) Bureau of TennCare (Bureau). The division
of the Tennessee Department of Finance and Administration, the single state
Medicaid agency, that administers the TennCare Program. For purposes of this
Chapter, the Bureau shall represent the State of Tennessee.
(6) Civil Penalty. A monetary penalty
assessed by the Bureau against a provider in an amount of not less than $1,000
nor more than $5,000 for each violation of the Tennessee Medicaid False Claims
Act. T.C.A. §
(7) Claim. Any request or demand for money,
property, or services made to any employee, officer, or agent of the state, or
to any contractor, grantee, or other recipient, whether under contract or not,
if any portion of the money, property, or services requested or demanded was
issued from, or was provided by, the State.
(8) Commissioner. The chief administrative
officer of the Tennessee Department where the Bureau is administratively
Designee. A person authorized by the Commissioner to review appeals of initial
orders and to enter final orders pursuant to T.C.A. §
4-5-315, or to review petitions for
stay or reconsideration of final orders.
(10) Contested Case. An administrative
proceeding in which the legal rights, duties or privileges of a party are
required by any statute or constitutional provision to be determined by an
agency after an opportunity for a hearing.
(11) Credible Allegation of Fraud.
Information which has been verified by the Bureau through judicious
case-by-case review and found to contain indicia of reliability. This
information may be from any source, including but not limited to hotline
complaints, claims data mining, patterns identified through provider audits,
civil false claims cases, or law enforcement investigations.
(12) Department. The Tennessee Department of
Finance and Administration.
Electronic Health Record Incentive Program (EHR-IP). The provisions of the
American Recovery and Reinvestment Act of 2009 (ARRA) that provide for
incentive payments to eligible professionals (EPs) and eligible hospitals
(EHs), including acute care, children's and critical access hospitals (CAHs)
participating in Medicare and Medicaid programs that adopt, implement or update
a certified system and successfully demonstrate meaningful use of certified
electronic health record (EHR) technology as required by federal
(14) Enrollee. An
individual eligible for and enrolled in the TennCare program.
(15) Error Rate. The percentage of claims in
a sample population that was not billed properly and is actionable. Error rates
can be applied to entire populations if the sample was the result of statically
valid random sampling. The use of the term "error" does not indicate the intent
of the person or entity submitting the claim.
(16) Findings of Fact. The factual findings
issued by the Administrative Judge or Commissioner's Designee following an
administrative hearing. The factual findings are enumerated in the initial
and/or final order. An order must include a concise and explicit statement of
the underlying facts of record to support the findings.
(17) Final Agency Decision. A Final
(18) Final Order. An initial
order becomes a final order without further notice if not timely appealed, or
if the initial order is appealed pursuant to T.C.A. §
4-5-315, the Commissioner or
Commissioner's Designee may render a final order. A statement of the procedures
and time limits for seeking reconsideration or judicial review shall be
included with the issuance of a final order.
Good Cause Not to Suspend Payment. The
Bureau may determine not to suspend payment or not to continue suspension of
payment to a provider being investigated due to a credible allegation of fraud
(a) Law enforcement officials have
specifically requested that a payment suspension not be imposed because such a
payment suspension may compromise or jeopardize an investigation;
(b) Other available remedies implemented by
the State more effectively or quickly protect Program funds;
(c) The Bureau determines, based upon the
submission of written evidence by the provider that is the subject of the
payment suspension, that the suspension should be removed;
(d) Enrollee access to items or services
would be jeopardized by a payment suspension because the provider is the sole
community physician, the sole source of essential specialized services in a
community, or serves a large number of enrollees within a HRSA-designated
medically underserved area;
enforcement declines to certify that a matter continues to be under
(f) The Bureau
determines that payment suspension is not in the best interests of the
to Suspend Payment Only in Part. The Bureau may determine to suspend payments
in part, or to convert a payment suspension previously imposed in whole to one
only in part, to a provider being investigated due to a credible allegation of
(a) Enrollee access to items or
services would be jeopardized by a payment suspension in whole or part because
the provider is the sole community physician, the sole source of essential
specialized services in a community, or serves a large number of recipients
within a HRSA-designated medically underserved area;
(b) The Bureau determines, based upon the
submission of written evidence by the provider that is the subject of a whole
payment suspension, that such suspension should be imposed only in
(c) The credible allegation
focuses solely and definitively on only a specific type of claim or arises from
only a specific business unit of a provider, and the Bureau determines and
documents in writing that a payment suspension in part would effectively ensure
that potentially fraudulent claims were not continuing to be paid;
(d) Law enforcement declines to certify that
a matter continues to be under investigation; or
(e) The Bureau determines that payment
suspension only in part is in the best interests of the Program.
(21) Hearing. A contested case
Reliability. Factors which the Bureau will examine in determining whether a
credible allegation of fraud exists, requiring the suspension of payments to a
provider, including but not limited to:
conflict (disgruntled employee);
(d) Prior bad acts;
(e) Pattern of bad acts;
(f) Documentary proof;
(g) Admission by provider;
(h) Expert opinion; or
(i) Indictment by a court of competent
Initial Order. The decision issued by the administrative judge following a
hearing. The initial order shall contain the decision, findings of fact,
conclusions of law, the policy reasons for the decision and the remedy
prescribed. It shall include a statement of the procedure for filing an appeal
of the initial order as well as a statement of any circumstances under which
the initial order may, without further notice, become a final order. A
statement of the procedures and time limits for seeking reconsideration or
other administrative relief and the time limits for seeking judicial review
shall be included.
(24) Notice of
Action. The document or letter sent by the Bureau to a provider detailing the
action the Bureau intends to take against the provider. The notice shall
include a statement of the reasons and authority for the action as well as a
statement of the provider's right to appeal the action, if
(25) Notice of Hearing.
The pleading filed with the Administrative Procedures Division by the Bureau
upon receipt of an appeal. It shall contain a statement of the time, place,
nature of the hearing, and the right to be represented by counsel; a statement
of the legal authority and jurisdiction under which the hearing is to be held,
referring to the particular statutes and rules involved; and, a short and plain
statement of the matters asserted, in compliance with the APA.
(26) Program. See TennCare.
Provider with Prescribing Authority. A
health care professional authorized by law or regulation to order prescription
medications for her patients and who:
Participates in the provider network of the MCC in which the beneficiary is
(b) Has received a
referral of the beneficiary, approved by the MCC, authorizing her to treat the
(c) In the case of
a TennCare beneficiary who is also enrolled in Medicare, is authorized to treat
RAT-STATS. A widely accepted statistical software tool designed to assist the
user in conducting statistically valid random sampling and evaluating audit
(29) Standard of Proof. A
preponderance of the evidence.
Statistically Valid Random Sampling. A method for determining error rates in
healthcare billings using extrapolation. Typically used for large numbers of
suspect claims or patients, a random sample of claims from a chosen population
is selected using RAT-STATS or a similar program. That sample is then analyzed
for errors. If the sample is the result of statistically valid random sampling,
the error rate in the sample can be extrapolated to the entire population of
(31) TennCare. The program
administered by the Single State Agency as designated by the State and CMS
pursuant to Title XIX of the Social Security Act and the Section 1115 Research
and Demonstration Waiver granted to the State of Tennessee.
(32) Tennessee Medicaid Provider Number. The
identifying number issued by the Bureau to an approved provider for the purpose
of receiving payment in exchange for rendering services to TennCare
(33) Tennessee Medicaid
False Claims Act (Act). T.C.A. §§
(34) Termination. The
deactivation of a provider's Tennessee Medicaid Provider Number and the
cessation of the provider's TennCare billing privileges.