On October 26, 1999, in response to a class-action lawsuit filed against TennCare, the Tennessee Office of General Counsel entered into a Revised Consent Decree (RCD) with the Tennessee Justice Center who was representing TennCare enrollees. The RCD outlines specific appeal rights for TennCare enrollees, revises some of the terms under which the appeals process is operationalized, and directs that time-sensitive notifications be provided to every TennCare enrollee. All of the provisions of the RCD went into effect November 1, 2000.
TennCare enrollees have always had the right to appeal to TennCare whenever they disagreed with actions taken by their Managed Care Organizations (MCOs). The RCD revises some of the terms under which the appeals process is operated.
Key Terms of the Revised Consent Decree
The key provisions of the consent decree specify:
· The timing and consent of letters to be used to inform TennCare enrollees that a service has been denied, terminated, suspended, reduced, or delayed. Any clinical decision conveyed in a letter must be supported by an individualized determination of medical necessity based upon the needs of the TennCare enrollee and his/her medical history. TennCare providers should be aware that the clinical decisions or opinions of the treating provider are not to be overturned by the health plans or TennCare unless there is substantial and material, documented medical evidence to justify such action.
· Two-business days advance notice is required when a provider initiates the termination, reduction, or suspension of certain types of services specified in the RCD.
· The correct action to be taken when an MCO fails to comply with the notice requirements or to meet the various required time frames for resolving an appeal.
· What and when an enrollee can appeal.
· If a TennCare enrollee presents a prescription that is non-formulary or requires prior approval that has not been obtained, the pharmacist must attempt to contact the prescriber to obtain a substitute prescription, or must attempt to obtain approval from Script Pharmacy Solutions. If a prior approval or a substituted prescription is not obtained while the enrollee is at the pharmacy, the pharmacist must provide up to a 14-day supply of the medication. An enrollee will not receive a 14-day supply if an alternative medication has been prescribed but is refused by the enrollee. Pharmacists are not to provide a medication if it is medically contraindicated for that particular enrollee, or if the Federal Drug Administration has determined that the medication is not effective, or the medication is not covered by the TennCare program. If the pharmacist is unable to fill a prescription, or a substitute prescription is ordered, the pharmacist must provide the enrollee written notice of his/her right to appeal.
· How services may be continued during an appeal if the appeal is requested timely, and the services are not medically contraindicated.
Providers in TLC's network are encouraged to use medications included in TLC's formulary whenever medically indicated. If the enrollee needs a medication that is not on the formulary, provide the rationale and supporting documentation for such a need as required for prior authorization or medical necessity. TLC receives a daily report of 14-day supplies which were issued on the prior day. We will communicate potential alternatives to you in an effort to increase awareness and decrease the necessity for the 14-day supply of medications.
· Grier requires that participating providers display a poster, which lists appeal rights in a conspicuous location in your office or facility.
· The Bureau will supply you with appeal forms, which you are asked to provide as needed to TennCare members.
· Grier requires that at discharge from inpatient and/or home health services, all TennCare members are to be given discharge instructions. This requirement will not veer from that which is required by most hospitals.
Notification of Enrollees
A poster describing enrollee appeal rights must be prominently displayed in the provider's office. The location should be such that a TennCare enrollee visiting your office or facility would be likely to see the poster.
Processing Appeals at TennCare
The TennCare Solutions Unit (TSU) has the responsibility for the pre-hearing portion of the TennCare appeals process. Their goal is to resolve problems as early in the process as possible.
They have toll-free phone lines available to enrollees who need assistance. The TSU toll-free telephone number is 1-800-878-3192; the toll-free fax number is 1-888-345-5575.
It is important that patients understand and have the opportunity to exercise their appeal rights. However, unnecessary appeals can delay timely needed care. To help prevent unnecessary appeals
Providers should:
· Follow TLC requirements regarding prior authorization
· Always provide good documentation of the need for care or services when requesting prior authorization
· Promptly respond to requests for additional medical information
· When prescribing a medication, use TLC's formulary. If the enrollee needs a medication that is not formulary, provide the rationale and supporting documentation for such a need
· Explain the difference between formulary and non-formulary drugs. This is especially important when patients request a specific brand-name drug that has been widely advertised and another comparable drug is available under TLC's formulary with the same efficacy
Enrollee Appeal Rights
1. The enrollee has the right to appeal if the enrollee cannot get the health care he/she needs when he/she needs it. The enrollee can appeal even if he/she does not have a doctor to prescribe what he/she needs. The enrollee has 30 days to appeal. The 30 days start when the enrollee finds out there is a problem.
2. If the enrollee appeals, someone else will take a look at what the enrollee needs. They will try to fix it quickly. If they cannot, the enrollee will get a chance to tell his/her side of the story to someone who does not work for TennCare.
3. The Enrollee has the right to get a letter from us if we (1) do not give the enrollee care, or (2) stop or cut the enrollee's care, or (3) make the enrollee wait too long for medical care. The letter must say why we decided this and what the enrollee can do about it.
4. The enrollee has the right to an answer when he/she needs it. The enrollee should have his/her TennCare health plan's OK ahead of time for certain types of care. If we take longer than 21 days to decide, we MUST give the enrollee the care he/she asked for. The enrollee can appeal before the end of the 21 days if the care he/she needs cannot wait that long.
5. The enrollee can get a fast appeal in some cases. The enrollee or the enrollee's provider must think the care is needed right away. The enrollee should tell TennCare why he/she needs a fast appeal.
6. If the enrollee is already getting care, he/she may be able to keep getting it during the appeal. To do this, the enrollee must appeal by the date his/his care will be cut or stopped (usually 2 to 10 days). The enrollee must say that his/her want to keep getting the care during the appeal. If the enrollee must have a doctor's order or prescription for the care, the enrollee can only keep getting the care if he/she has a doctor's order or prescription. If the appeal is decided against the enrollee, he/she might have to repay TennCare for the cost of the care the enrollee got during the enrollee's appeal.
7. In most cases, the enrollee has a right to get medicine even if the drug store says TennCare does not cover this drug. The enrollee may get a different drug that his/her doctors has OK'd. If not, he/she will get some of the drug his/her doctor ordered. NOTE: You will not get the medicine if:
(a) It would not be safe for the enrollee, OR
(b) It is a drug that does not work, OR
(c) It is a drug that is part of a group of drugs that TennCare does not cover for adults.
8. The enrollee may have the right to be told before we cut the care he/she are getting. If we decide to cut his/her care; the enrollee has the right to be warned in writing 10 days before it happens. If the enrollee's DOCTOR wants to cut his/her medical care the enrollee have the right to a two-day warning if:
(a) The enrollee is getting inpatient psychiatric or residential services; OR
(b) The enrollee's TennCare health plan cannot get the care right away that he/she needs next for his/her long-term health problem; OR
(c) The enrollee is getting home health services.
9. The enrollee has the right to have TennCare pay his/her medical bills. Is the enrollee getting the bills that TennCare should pay for? The enrollee must appeal within 30 days after he/she get the bill.
Enrollee TennCare Hearing Rights
The enrollee has the right to:
1. Have a hearing if the enrollee problem is not fixed.
2. Know about the hearing 3 weeks ahead of time (1 week for fast appeals).
3. Be at the hearing in person or by phone.
4. Speak for him/herself at the hearing.
5. The enrollee can have someone to help him/her at the hearing.
6. See the information TennCare and his/her health plan used to decide about the care.
7. The enrollee can see this before the hearing.
8. The enrollee can look at his/her records and use them as proof.
9. The enrollee can give the judge proof about his/her health and medical care.
10. The enrollee can bring witnesses to testify for him/her.
11. Have the judge order his/her witnesses to come.
12. Question witnesses for TennCare.
13. Show proof that the health plan made the wrong decision.
14. Ask to have a doctor who does not work for TennCare say what medical care the enrollee needs. The enrollee does not have to pay for this.
15. Get a written decision in 90 days (31 days if it was a fast appeal).
16. If the decision is late, the enrollee can get medical care until the decision is made. This is NOT true if he/she is the reason the decision is late.
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