Tenn. Comp. R. & Regs. 1200-13-18-.04 – Recoupment or Withhold

(1) The Bureau is required by state and federal law to protect the integrity of the Medicaid program. This is accomplished in part by causing audits of provider claims to be conducted. Audit findings are reported to the Bureau for the purpose of recovering incorrect payments, by recoupment or withhold.
(2) The Bureau shall notify a provider of its intent to recoup or withhold based upon audit findings by issuing a notice of action. Each notice of action sent to a provider shall contain the proposed recovery action and the following information:
1. (a) The name and contact information of an individual knowledgeable about the audit findings and who is authorized to discuss the proposed recovery action with the provider;
2. (b) The manner by which the provider may submit additional information to support his disagreement with the proposed recovery action;
3. (c) A statement that the provider has the right to appeal the proposed recovery action and the manner in which an appeal must be filed.
(3) Any appeal of a notice of action shall be conducted according to rule .01 of this chapter.
(4) The audit and the audit findings are not subject to appeal. (See NHC v. Snodgrass, 555 S.W.2d 403 (Tenn. 1977)). 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.