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Administrative Manual

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

December 2, 2015 Division of TennCare 2

• A decision regarding eligibility for TennCare Medicaid or CoverKids, such as a denial for eligibility or eligibility begin date; • Termination of TennCare Medicaid or CoverKids benefits; • Failure to make a timely eligibility determination; • Discriminatory treatment or practice (See Rights and Responsibilities policy); and • Amount of a co-pay obligation for TennCare Medicaid or CoverKids.

4. Timely Appeal

An appeal filed within 40 days from the date of the termination or denial notice is considered timely. Benefits will be continued if the request is filed within 20 days of the notice or before the end date of coverage if that is later, pending the final decision of the Administrative Judge. However, the individual must be informed that if HCFA’s decision is upheld, he or she may be responsible for repaying the benefits paid pending the decision. If benefits are to continue pending the outcome of the appeal, the Eligibility Appeals Unit will manually continue the benefits, as applicable.

If benefits are continued, HCFA will not terminate benefits before a decision is reached unless:

• It is determined at the hearing the issue at hand is one of federal or state law or policy; and • HCFA informs the beneficiary in writing that services will be terminated or reduced pending the hearing decision.

5. Good Cause for an Untimely Appeal Appeals may be accepted after the 40 day time limit if the appellant can show good cause as to why the appeal could not be filed within 40 days. In addition, benefits can be continued if the appellant can show good cause for failing to file the request within 20 days. The decision regarding good cause is made by designated attorneys within the Eligibility Appeals Unit.

6. Filing an Appeal

An individual may file an appeal by phone, mail, or fax. Individuals may file appeals with TNHC.

Mailing Address: Tennessee Health Connection P.O. Box 305240 Nashville, TN 37230-5240

Toll-free Phone: 1-855-259-0701

Toll-free Fax: 1-855-315-0669