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Administrative Manual Section: General Administrative Procedures and Compliance Policy Manual Number: 200.055 Chapter: Appeals

Legal Authority: 42 CFR 431.205; 42 CFR 431.206; 42 CFR 431.230; 42 CFR 431.221

1. Policy Statement

Applicants and enrollees in TennCare Medicaid and CoverKids may file an appeal with HCFA when dissatisfied with an action taken on the individual’s eligibility case. Appeal requests will be given prompt and careful attention, and corrective action, when indicated, will be taken immediately. Tennessee Health Connection (TNHC) or HCFA staff will provide the appellant with a HCFA Appeal form, or complete the form on the individual’s behalf. HCFA must provide whatever assistance the complainant requires in appealing for a fair hearing.

2. Appeal Rights Every applicant and recipient of TennCare Medicaid and CoverKids has the right to appeal if he or she is aggrieved by an action or lack of action taken by HCFA. Individuals should be informed of their right to a hearing, how to obtain a hearing, and that the individual may represent himself or herself, use legal counsel, a relative, a friend or other spokesman. An individual must be informed of his or her hearing rights: • At application; • When an action taken by HCFA affects his or her claim; • When a skilled nursing facility or nursing facility notifies a resident of a transfer or discharge (not including movement to a bed within the same certified facility); and • When an individual receives an adverse action from a preadmission screening and annual resident review under §1919(e)(7) of the Social Security Act. HCFA will inform the individual of free legal representation that is readily available in the individual’s area. All HCFA hearing records and decisions are available for public inspection and copying, subject to the disclosure safeguards provided by federal regulations. The names and addresses of appellants will be kept confidential.

3. Appealable Actions

Appeals may arise from conflicts or dissatisfaction related to an action or lack of action by HCFA such as, but not limited to: