Tenn. Comp. R. & Regs. 1200-13-18-.05 – Suspension of Payment

(1) Pursuant to 42 C.F.R. § 447.90, the Bureau is prohibited by federal law from receiving federal financial participation (FFP) for payment to a provider of medical items or services with respect to which there is a pending investigation of a credible allegation of fraud, absent good cause not to suspend payment or good cause to suspend payment only in part.
(2) The Bureau must provide written notice to the provider of a suspension of payments:
1. (a) Five (5) days after suspending payments unless a law enforcement agency has submitted a written request to delay the notice; or
2. (b) Thirty (30) days after suspending payments when a delay was properly requested by law enforcement, except the delay may be renewed twice in writing not to exceed ninety (90) days.
(3) Written notice of suspension of payment must contain:
1. (a) A statement that payments are suspended according to this rule and federal regulation;
2. (b) The general allegations as to the nature of the suspension action, but need not disclose any specific information concerning an ongoing investigation;
3. (c) A statement that the suspension is temporary and the circumstances under which it will be terminated;
4. (d) If applicable, state the type(s) of TennCare/Medicaid claims to which suspension is effective;
5. (e) A statement that the provider has the right to submit written evidence for consideration by the Bureau; and
6. (f) A statement that the provider has the right to appeal the suspension and the manner in which an appeal must be filed.
(4) Any appeal of a notice of suspension of payment shall be conducted according to rule .01 of this chapter.
(5) Any suspension of payment shall be temporary and shall not continue after:
1. (a) The Bureau or prosecuting authority determines there is insufficient evidence of fraud by the provider; or
2. (b) Legal proceedings related to the provider’s alleged fraud are completed.
(6) The Bureau must document in writing the termination of a suspension of payment. Such document must include any applicable appeal rights available to the provider. 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.