Tenn. Comp. R. & Regs. 1200-13-18-.02 – Definitions

(1) Administrative Judge. An employee or official of the Office of the Secretary of State who is licensed to practice law and authorized by law to conduct contested case proceedings.
(2) Administrative Procedures Act (APA). The Tennessee Uniform Administrative Procedures Act, as amended, codified at T.C.A. §§ 4-5-301, et seq.
(3) Approved Provider. A provider of health care services who has registered with and been approved by the Bureau and has been issued a Tennessee Medicaid Provider Number.
(4) Audit. The systematic process of objectively obtaining and evaluating evidence regarding assertions about economic actions and events to ascertain the degree of correspondence between those assertions and established criteria and communicating the results to interested parties. Audits are conducted in accordance with AICPA (American Institute of Certified Public Accountants) auditing or attestation engagement standards. For purposes of this chapter, audits are conducted of health care provider records, financial information, and statistical data according to principles of cost reimbursement to determine the reasonableness and allowance of costs reimbursable under the Program. Statistically valid random sampling is used to determine actual damages.
(5) Bureau of TennCare (Bureau). The division of the Tennessee Department of Finance and Administration, the single state Medicaid agency, that administers the TennCare Program. For purposes of this Chapter, the Bureau shall represent the State of Tennessee.
(6) Civil Penalty. A monetary penalty assessed by the Bureau against a provider in an amount of not less than $1,000 nor more than $5,000 for each violation of the Tennessee Medicaid False Claims Act. T.C.A. § 71-5-183(h)(3).
(7) Claim. Any request or demand for money, property, or services made to any employee, officer, or agent of the state, or to any contractor, grantee, or other recipient, whether under contract or not, if any portion of the money, property, or services requested or demanded was issued from, or was provided by, the State.
(8) Commissioner. The chief administrative officer of the Tennessee Department where the Bureau is administratively located.
(9) Commissioner’s Designee. A person authorized by the Commissioner to review appeals of initial orders and to enter final orders pursuant to T.C.A. § 4-5-315, or to review petitions for stay or reconsideration of final orders.
(10) Contested Case. An administrative proceeding in which the legal rights, duties or privileges of a party are required by any statute or constitutional provision to be determined by an agency after an opportunity for a hearing.
(11) Credible Allegation of Fraud. Information which has been verified by the Bureau through judicious case-by-case review and found to contain indicia of reliability. This information may be from any source, including but not limited to hotline complaints, claims data mining, patterns identified through provider audits, civil false claims cases, or law enforcement investigations.
(12) Department. The Tennessee Department of Finance and Administration.
(13) Electronic Health Record Incentive Program (EHR-IP). The provisions of the American Recovery and Reinvestment Act of 2009 (ARRA) that provide for incentive payments to eligible professionals (EPs) and eligible hospitals (EHs), including acute care, children’s and critical access hospitals (CAHs) participating in Medicare and Medicaid programs that adopt, implement or update a certified system and successfully demonstrate meaningful use of certified electronic health record (EHR) technology as required by federal regulations.
(14) Enrollee. An individual eligible for and enrolled in the TennCare program.
(15) Error Rate. The percentage of claims in a sample population that was not billed properly and is actionable. Error rates can be applied to entire populations if the sample was the result of statically valid random sampling. The use of the term “error” does not indicate the intent of the person or entity submitting the claim.
(16) Findings of Fact. The factual findings issued by the Administrative Judge or Commissioner’s Designee following an administrative hearing. The factual findings are enumerated in the initial and/or final order. An order must include a concise and explicit statement of the underlying facts of record to support the findings.
(17) Final Agency Decision. A Final Order.
(18) Final Order. An initial order becomes a final order without further notice if not timely appealed, or if the initial order is appealed pursuant to T.C.A. § 4-5-315, the Commissioner or Commissioner’s Designee may render a final order. A statement of the procedures and time limits for seeking reconsideration or judicial review shall be included with the issuance of a final order.
(19) Good Cause Not to Suspend Payment. The Bureau may determine not to suspend payment or not to continue suspension of payment to a provider being investigated due to a credible allegation of fraud if:
1. (a) Law enforcement officials have specifically requested that a payment suspension not be imposed because such a payment suspension may compromise or jeopardize an investigation;
2. (b) Other available remedies implemented by the State more effectively or quickly protect Program funds;
3. (c) The Bureau determines, based upon the submission of written evidence by the provider that is the subject of the payment suspension, that the suspension should be removed;
4. (d) Enrollee access to items or services would be jeopardized by a payment suspension because the provider is the sole community physician, the sole source of essential specialized services in a community, or serves a large number of enrollees within a HRSA-designated medically underserved area;
5. (e) Law enforcement declines to certify that a matter continues to be under investigation; or
6. (f) The Bureau determines that payment suspension is not in the best interests of the Program.
(20) Good Cause to Suspend Payment Only in Part. The Bureau may determine to suspend payments in part, or to convert a payment suspension previously imposed in whole to one only in part, to a provider being investigated due to a credible allegation of fraud if:
1. (a) Enrollee access to items or services would be jeopardized by a payment suspension in whole or part because the provider is the sole community physician, the sole source of essential specialized services in a community, or serves a large number of recipients within a HRSA-designated medically underserved area;
2. (b) The Bureau determines, based upon the submission of written evidence by the provider that is the subject of a whole payment suspension, that such suspension should be imposed only in part;
3. (c) The credible allegation focuses solely and definitively on only a specific type of claim or arises from only a specific business unit of a provider, and the Bureau determines and documents in writing that a payment suspension in part would effectively ensure that potentially fraudulent claims were not continuing to be paid;
4. (d) Law enforcement declines to certify that a matter continues to be under investigation; or
5. (e) The Bureau determines that payment suspension only in part is in the best interests of the Program.
(21) Hearing. A contested case proceeding.
(22) Indicia of Reliability. Factors which the Bureau will examine in determining whether a credible allegation of fraud exists, requiring the suspension of payments to a provider, including but not limited to:
1. (a) Firsthand knowledge;
2. (b) Corroborating witness;
3. (c) Witness conflict (disgruntled employee);
4. (d) Prior bad acts;
5. (e) Pattern of bad acts;
6. (f) Documentary proof;
7. (g) Admission by provider;
8. (h) Expert opinion; or
9. (i) Indictment by a court of competent jurisdiction.
(23) Initial Order. The decision issued by the administrative judge following a hearing. The initial order shall contain the decision, findings of fact, conclusions of law, the policy reasons for the decision and the remedy prescribed. It shall include a statement of the procedure for filing an appeal of the initial order as well as a statement of any circumstances under which the initial order may, without further notice, become a final order. A statement of the procedures and time limits for seeking reconsideration or other administrative relief and the time limits for seeking judicial review shall be included.
(24) Notice of Action. The document or letter sent by the Bureau to a provider detailing the action the Bureau intends to take against the provider. The notice shall include a statement of the reasons and authority for the action as well as a statement of the provider’s right to appeal the action, if applicable.
(25) Notice of Hearing. The pleading filed with the Administrative Procedures Division by the Bureau upon receipt of an appeal. It shall contain a statement of the time, place, nature of the hearing, and the right to be represented by counsel; a statement of the legal authority and jurisdiction under which the hearing is to be held, referring to the particular statutes and rules involved; and, a short and plain statement of the matters asserted, in compliance with the APA.
(26) Program. See TennCare.
(27) Provider with Prescribing Authority. A health care professional authorized by law or regulation to order prescription medications for her patients and who:
1. (a) Participates in the provider network of the MCC in which the beneficiary is enrolled; or
2. (b) Has received a referral of the beneficiary, approved by the MCC, authorizing her to treat the beneficiary; or,
3. (c) In the case of a TennCare beneficiary who is also enrolled in Medicare, is authorized to treat Medicare patients.
(28) RAT-STATS. A widely accepted statistical software tool designed to assist the user in conducting statistically valid random sampling and evaluating audit results.
(29) Standard of Proof. A preponderance of the evidence.
(30) Statistically Valid Random Sampling. A method for determining error rates in healthcare billings using extrapolation. Typically used for large numbers of suspect claims or patients, a random sample of claims from a chosen population is selected using RAT-STATS or a similar program. That sample is then analyzed for errors. If the sample is the result of statistically valid random sampling, the error rate in the sample can be extrapolated to the entire population of claims.
(31) TennCare. The program administered by the Single State Agency as designated by the State and CMS pursuant to Title XIX of the Social Security Act and the Section 1115 Research and Demonstration Waiver granted to the State of Tennessee.
(32) Tennessee Medicaid Provider Number. The identifying number issued by the Bureau to an approved provider for the purpose of receiving payment in exchange for rendering services to TennCare enrollees.
(33) Tennessee Medicaid False Claims Act (Act). T.C.A. §§ 71-5-181, et seq.
(34) Termination. The deactivation of a provider’s Tennessee Medicaid Provider Number and the cessation of the provider’s TennCare billing privileges. Statutory Authority: T.C.A. §§ 4-5-202, 71-5-105 and 71-5-109. Administrative History: Emergency rule filed February 18, 2011; effective through August 17, 2011. Original rule filed May 18, 2011; effective August 16, 2011. Amendment filed January 15, 2013; effective April 15, 2013.