Section 1200-13-18-.07 - TERMINATION OR EXCLUSION OF A PROVIDER FROM PROGRAM PARTICIPATION(1) A provider may be terminated or excluded from participation in the TennCare program.(2) Federal Mandatory Exclusion. The Bureau is required by federal law to exclude a provider from participation in the TennCare program upon notice from HHS or CMS under the following circumstances: (a) Conviction of program-related crimes;(b) Conviction relating to patient abuse;(c) Felony conviction relating to health care fraud; or(d) Felony conviction relating to controlled substance.(3) Federal Permissive Exclusion. Pursuant to federal law, the Bureau may exclude a provider from participation in the TennCare program under the following circumstances:(a) Conviction related to fraud;(b) Conviction related to obstruction of an investigation or audit;(c) Misdemeanor conviction related to controlled substance;(d) License revocation or suspension;(e) Exclusion or suspension under federal or state health care program;(f) Claims for excessive charges or unnecessary services and failure of certain organizations to furnish medically necessary services;(g) Fraud, kickbacks, and other prohibited activities;(h) Entities controlled by a sanctioned individual;(i) Failure to disclose required information;(j) Failure to supply requested information on subcontractors and suppliers;(k) Failure to supply payment information;(l) Failure to grant immediate access;(m) Failure to take corrective action;(n) Default on health education loan or scholarship obligations;(o) Individuals controlling a sanctioned entity; or(p) Making false statements or misrepresentation of material facts.(4) When a provider exclusion is mandatory, the notice of action shall state that the provider has no right to appeal the termination from program participation.(5) When a provider exclusion is permissive, the notice of action shall include a statement that the provider has the right to appeal the termination from program participation and the manner in which an appeal must be filed.Tenn. Comp. R. & Regs. 1200-13-18-.07
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.