1200-13-16-.08

Tenn. Comp. R. & Regs. 1200-13-16-.08

Right to Appeal a Medical Necessity Determination

Effective May 15, 2007Authority: T.C.A. §§ 4-5-209, 71-5-105, 71-5-109, Executive Order No. 23.Tennessee Department of Health, Tennessee Department of Environment and Conservation, and, Tennessee Department of Finance and Administration

An enrollee may appeal a determination that a medical item or service that is within the enrollee’s scope of covered benefits is not medically necessary. In all such appeals, the burden of proof will rest with the enrollee at all stages.

Authority: T.C.A. §§ 4-5-209, 71-5-105, 71-5-109, Executive Order No. 23. Administrative History: Public necessity rule filed December 1, 2006; expires May 15, 2007. Original rule filed March 1, 2007; effective May 15, 2007.