09 REVIEW OF COVERKIDS DECISIONS

(1) Eligibility and Enrollment Matters. Administrative review of matters related to eligibility and enrollment shall be conducted as set out in Chapter 1200-13-19. (2) Adverse Medical and Dental Benefit Determination Matters. A parent or authorized representative of a CoverKids enrollee may request review of a CoverKids action to delay, deny, reduce, suspend, or terminate medical and dental services, or a failure to approve, furnish, or provide payment for medical and dental services in a timely manner, according to Rule 1200-13-13-.11, except that enrollees shall not be entitled to continuation of benefits pursuant to 42 CFR § 457.1260. (3) Adverse Pharmacy Benefit Determination Matters. A parent or authorized representative of a CoverKids enrollee may request review of a CoverKids action to delay, deny, reduce, suspend, or terminate pharmacy services, or a failure to approve, furnish, or provide payment for pharmacy services in a timely manner, according to the following provisions: (a) Notice. Any decision denying or delaying a requested pharmacy service, reducing, suspending or terminating an existing pharmacy service, or failure to approve, furnish or provide payment for pharmacy services in a timely manner shall be in writing and must contain the reason for the determination, an explanation of review rights and procedures, the standard and expedited time frames for review, the manner of requesting a review, and the circumstances under which existing pharmacy services may continue pending review unless there is question that the existing pharmacy services are harmful. (b) Pharmacy Plan Administrator (PPA) Review. A parent or authorized representative may commence the review process by submitting a written request to the PPA within 30 days of issuance of written notice of the action or, if no notice is provided, from the time the enrollee becomes aware of the action, not to exceed six (6) months from when the action occurred. The PPA will review this request and issue a written decision within 30 days of receipt of this request. Expedited reviews (within 72 hours) will be available for situations in which a benefit determination or a preauthorization denial has been made prior to services being received and the attending medical professional determines the medical situation to be life threatening or would seriously jeopardize the enrollee’s life, physical or mental health, or ability to attain, maintain or regain maximum function. This determination should be made in legible writing with an original signature. (c) State Informal Review. After the PPA’s internal review is completed, the parent or authorized representative of an enrollee who disagrees with the decision may request further review by telephone or by submitting a letter or form to the Division of TennCare, CoverKids Appeals, which must be received within 8 days of the PPA’s decision. The Appeals Coordinator will review the matter and gather supplemental information from the family, physician, and/or insurer as needed. The Appeals Coordinator will request review by the state’s independent medical consultant and a written decision will be issued within 20 days of receipt of the request for further review. (d) State Review Committee. If the informal review does not grant the relief requested by the parent or authorized representative, the request will be scheduled for review by the CoverKids Review Committee. The Committee will be composed of five members, including Division of TennCare staff and at least one independent licensed medical professional. The members of the Committee will not have been directly involved in the matter under review. The parent or authorized representative will be given the opportunity to review the file, be represented by a representative of the parent’s or authorized representative’s choice, and provide supplemental information. The Committee may allow the parent or authorized representative to appear in person if it finds that scheduling the appearance will not cause delay in the review process. The Review Committee is not required to provide an in-person hearing or a contested case under the Uniform Administrative Procedures Act. The parent or authorized representative will receive written notification of the final decision stating the reasons for the decision. The decision of the CoverKids Review Committee is the final administrative recourse available to the member. (e) Time for Reviews. Review of all non-expedited pharmacy services appeals will be completed within 90 days of receipt of the initial request for review by the PPA. Reviews by both the Appeals Coordinator and the Committee may be expedited (completed within 72 hours at each of the PPA and state levels) for situations in which a benefit determination or a preauthorization denial has been made prior to services being received and the attending medical professional determines the medical situation to be life threatening or would seriously jeopardize the enrollee’s life, physical or mental health, or ability to attain, maintain or regain maximum function. This determination should be made in legible writing with an original signature. (4) Scope of Review. CoverKids will not provide a review process for a change in enrollment, eligibility, or coverage under the health benefits package required by a change in the state plan or federal and state law requiring an automatic change that affects all or a group of applicants or enrollees without regard to their individual circumstances. Authority: T.C.A. §§ 4-5-202, 4-5-204, 71-3-1106, and 71-3-1110; 42 U.S.C. §§ 1397aa, et seq.; and the Tennessee Title XXI Children’s Health Insurance Program State Plan. Administrative History: Original rules filed November 28, 2018; effective February 26, 2018. Rule was originally numbered 1200-13-21- .07 but was renumbered 1200-13-21-.09 with the introduction of new rules 1200-13-21-.04 and 1200-13- 01-.06 filed January 11, 2021; effective April 11, 2021. Amendments filed January 11, 2021; effective April 11, 2021.