(a) In order to protect TennCare patients and ensure the state‘s compliance with applicable federal regulations or court order, managed care organizations, behavioral health organizations and certain health care providers that receive TennCare funds shall comply with the following requirements:
Terms Used In Tennessee Code 71-5-139
Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
State: when applied to the different parts of the United States, includes the District of Columbia and the several territories of the United States. See Tennessee Code 1-3-105
(1) Whenever a TennCare enrollee is entitled under applicable federal regulations or court order to notice and an opportunity to appeal a provider initiated reduction, termination or suspension of inpatient hospital care, where the service being provided to the enrollee is to treat an enrollee’s chronic condition across a continuum of services when the next appropriate level of medical service is not immediately available, it shall be the duty of the hospital where the patient is receiving care to timely notify the patient’s managed care organization of that fact. The hospital shall also have a duty to cooperate with the managed care organization in the provision to the patient of timely notice of the patient’s rights under such applicable federal regulations or court order. In the event that a TennCare enrollee continues to receive inpatient care, as authorized by such applicable federal regulations or court order, because the next level of care prescribed for the patient is not immediately available, the managed care organization shall reimburse the hospital for such additional care. Nothing in this subdivision (a)(1) relieves the managed care organization of its ultimate responsibility for ensuring compliance with applicable federal regulations or court order, with respect to the provision of notice and services to the patient;(2) Whenever a TennCare enrollee is entitled under applicable federal regulations or court order to notice and an opportunity to appeal a provider initiated reduction, termination or suspension of home health services, it shall be the duty of the home care organization that has been caring for the patient to timely notify the patient’s managed care organization of the proposed change. The home care organization shall cooperate with the managed care organization in the provision to the patient of timely notice of the patient’s rights under such applicable federal regulations or court order. In the event that a TennCare enrollee continues to receive home health services, as authorized by such applicable federal regulations or court order, the managed care organization shall reimburse the home care organization for such additional services. Nothing in this subdivision (a)(2) relieves the managed care organization of its ultimate responsibility for ensuring compliance with applicable federal regulations or court order, with respect to the provision of notice and services to the patient;(3) Whenever a TennCare enrollee is entitled under applicable federal regulations or court order to notice and an opportunity to appeal a provider initiated reduction, termination or suspension of inpatient psychiatric or residential service, it shall be the duty of the facility where the patient is receiving care to timely notify the patient’s behavioral health organization of the proposed change. The facility shall also have a duty to cooperate with the behavioral health organization in the provision to the patient of timely notice of the patient’s rights under such applicable federal regulations or court order. In the event that a TennCare enrollee continues to receive inpatient or residential care, as authorized by such applicable federal regulations or court order, the behavioral health organization shall reimburse the facility for such additional care. Nothing in this subdivision (a)(3) relieves the behavioral health organization of its ultimate responsibility for ensuring compliance with applicable federal regulations or court order, with respect to the provision of notice and services to the patient; and(4) Whenever a TennCare enrollee who is classified as severely and persistently mentally ill, or severely emotionally disturbed, is entitled under applicable federal regulations or court order to notice and an opportunity to appeal a provider initiated reduction, termination or suspension of behavioral health service, it shall be the duty of the health care provider who is caring for the patient to timely notify the patient’s behavioral health organization of the proposed change. The provider shall also have a duty to cooperate with the behavioral health organization in the provision to the patient of timely notice of the patient’s rights under such applicable federal regulations or court order. In the event that a TennCare enrollee continues to receive such behavioral health service, as authorized by such applicable federal regulations or court order, the behavioral health organization shall reimburse the provider for that additional care. Nothing in this subdivision (a)(4) relieves the behavioral health organization of its ultimate responsibility for ensuring compliance with applicable federal regulations or court order, with respect to the provision of notice and services to the patient.(b) The commissioner of finance and administration is authorized to promulgate emergency rules pursuant to § 4-5-208 as necessary to implement this section.
