Section 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:(a) Five (5) days after suspending payments unless a law enforcement agency has submitted a written request to delay the notice; or(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:(a) A statement that payments are suspended according to this rule and federal regulation;(b) The general allegations as to the nature of the suspension action, but need not disclose any specific information concerning an ongoing investigation;(c) A statement that the suspension is temporary and the circumstances under which it will be terminated;(d) If applicable, state the type(s) of TennCare/Medicaid claims to which suspension is effective;(e) A statement that the provider has the right to submit written evidence for consideration by the Bureau; and(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: (a) The Bureau or prosecuting authority determines there is insufficient evidence of fraud by the provider; or(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.Tenn. Comp. R. & Regs. 1200-13-18-.05
Emergency rule filed February 18, 2011; effective through August 17, 2011. Original rule filed May 18, 2011; effective August 16, 2011.Statutory Authority: T.C.A. §§ 4-5-202, 71-5-105 and 71-5-109.