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Administrative Manual Section: General Administrative Procedures and Compliance Policy Manual Number: 200.040 Chapter: Eligibility Determination
Legal Authority: S e c . 1 9 0 2 o f t h e S o c i a l S e c u r i t y A c t [ 4 2 U S C 1 3 9 6 a ] ; 20 CFR 416.701; 20 CFR 416.708; 20 CFR 416.714; 42 CFR 435.906; 42 CFR 435.907; 42 CFR 435.908; 42 CFR 435.909; 42 CFR 435.910; 42 CFR 435.911; 42 CFR 435.912; 42 CFR 435.913; 42 CFR 435.915; 4 2 C F R 4 3 5 . 9 2 6 ; 4 2 C F R 4 3 5 . 1 7 2 ; 42 CFR 457.340; 42 CFR 457.330; 42 CFR 457.340; TennCare III Demonstration Waiver; Tenn. Comp. R. & Regs. 1200-13-20
1. Policy Statement
All valid applications are disposed of by a finding of eligibility or ineligibility, unless there is supporting documentation that the applicant is deceased prior to the application date, cannot be located, or has voluntarily withdrawn her application. An individual is eligible for TennCare Medicaid or CoverKids when he meets the financial and non-financial eligibility requirements. All facts used by TennCare to substantiate an eligibility determination are recorded in the individual’s case. A decision will be rendered in each case, and the individual will be notified of the decision.
2. Timely Determinations and Processing Time Limits
a. Processing Time Frames
An eligibility determination and notice of such determination must be sent to an individual:
i. Within ninety (90) days from the date of application for individuals applying for Medicaid based on a disability; or ii. Within forty-five (45) days from the date of application for all other individuals.
The above time standards are not used as a waiting period to determine eligibility, nor considered an acceptable reason to deny eligibility when the determination is not made within these standards.
b. Extension to Processing Time Frames
The 45 and 90-day processing time frame may be extended in the following situations:
i. The individual delays required action until the end of the allowed timeframe; ii. The individual has requested assistance in obtaining verifications; or iii. An administrative or other emergency beyond TennCare’s control.