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Proposed Legislation for TnCare Denial Process

HB0051 / SB0133 proposed by Rep. Matheny and Sen. Bowling would improve appeals of denied or partially denied TennCare claims by HMO’s. Key features include:

  • provider access to a designated contact for prompt claims resolution and in-person telephonic utilization review eight (8) hours per day, seven (7) days a week to receive requests for authorization of covered services and for initiating resolution of matters related to the payment or nonpayment of submitted claims
  • Establishing and maintaining an interactive website operated by the HMO that allows providers to file grievances, appeals, and documents in support thereof electronically in an encrypted HIPAA compliant format and that allows a provider to check on the status of matters on appeal or grievance
  • Establish procedures that require a written reply in detail sufficient to inform the provider of the reasons for any claims determination or matter related to a filed grievance. Providers shall receive the reply not later than ten (10) days following the day upon which it first was filed and may file for timely reconsideration of any claims determination
  • Consider and pay claims for the same or similar medical conditions of a patient that previously were paid but that have been denied and resubmitted by the provider for reconsideration outside any timely filing limitations of the managed care organization
  • Afford providers the opportunity for an in-person meeting with an informed representative of the HMO on any claim or set of claims that remain unpaid sixty (60) days or more past the date of the first determination and that individually or in the aggregate exceed ten thousand dollars ($10,000)

Download this legislation (PDF)