Section 1200-13-19-.05 - APPEAL RIGHTS, NOTICES AND PROCEDURES(1) The Agency must grant an opportunity for a hearing to the following: (a) Any applicant who requests it because his claim for services is denied or is not acted upon with reasonable promptness.(b) Any beneficiary who requests it because he believes the Agency has taken an action erroneously.(c) Any enrollee who is entitled to a hearing under 42 C.F.R. 438 subpart B.(2) The Agency need not grant a hearing if the sole issue is a Federal or State law requiring an automatic change adversely affecting some or all beneficiaries.(3) When the Agency receives an appeal from an appellant, the Agency will dismiss this appeal unless the appellant has established a valid factual dispute relating to the appeal. The Agency will screen all appeals submitted by appellants to determine if each appellant has presented a valid factual dispute. If the Agency determines that an appellant failed to present a valid factual dispute, the Agency will immediately provide the appellant with a notice informing him that he must provide additional information as identified in the notice. If the appellant does not provide this information within ten (10) days of the date of the notice, the appeal will be dismissed without the opportunity for a fair hearing. If the appellant adequately responds to this notice, the Agency will inform the appellant that the appeal will proceed to a hearing. If the appellant responds but fails to provide adequate information, the Agency will provide a notice to the appellant, informing him that the appeal is dismissed without the opportunity for a fair hearing. If the appellant does not respond, the appeal will be dismissed without the opportunity for a fair hearing, without further notice to the appellant.(4) The Agency must provide notice of his right to a hearing; of the method by which he may obtain a hearing; and that he may represent himself or use a representative at the time:(a) The individual applies for CoverKids or TennCare; and(b) Of any action affecting his eligibility.(5) The notice of appeal rights and procedures must contain:(a) A statement of what action the Agency intends to take;(b) The reasons for the intended action;(c) The specific rules that support, or the change in Federal or State law that requires, the action;(d) An explanation of: 1. The individual's right to request a hearing; or2. In cases of an action based on a change in law, the circumstances under which a hearing will be granted; and3. The circumstances under which Medicaid is continued if a hearing is requested.Tenn. Comp. R. & Regs. 1200-13-19-.05
Adopted effective May 6, 2015.Authority: T.C.A. §§ 4-5-208, 71-5-105 and 71-5-112; 42 U.S.C. §§ 1396 a(a)(3), (5), (8); 42 C.F.R. 431 Subpart E and 42 C.F.R. § 435.912.