Grier Revised Consent Decree

1. Grier Revised Consent Decree

2. Grier Revised Consent Decree • 1979 - Daniels vs. White • 1994 -TennCare • 1999 - Grier Revised Consent Decree

3. Key Provisions • Adequate notice • Appeal rights • Procedural protection • Appeal filed within 30 days

4. Key Provisions • 2 Types of appeals • Standard • Expedited • Medical necessity denials • Compliance requirements

5. Expedited Appeal Time sensitive - care constitutes an “emergency” • Serious health problems or death • Serious dysfunction of a bodily organ or part • Hospitalization

6. When Does Grier Apply? An Enrollee experiences an adverse action regarding TennCare benefits or services (medical assistance funded wholly or in part with federal funds under the Medicaid Act) administered by TennCare through their managed care contractors (MCC)

7. Adverse Action • Denial • Delay • Termination • Suspension • Reduction • Any act, or failure to act that impacts the quality, availability, or timeliness of a Medicaid MR Waiver Service to an eligible person

8. When Grier does not apply • State-funded services • Person is on the waiting list -not enrolled to receive Medicaid services • Services provided without PA • Rate Issues

9. Provider Responsibilities • Educate staff • Provide adequate network • Provide services as authorized • Provide services consistently and timely

10. Provider Responsibilities • Regional Office must be informed immediately upon any provider-initiated adverse action • Failure may result in sanctions or recoupment of funds by DIDD

11. Provider-Initiated Adverse Actions • The Regional Office must be informed a minimum of 60 daysbefore ceasing to provide services • Services must continue until a new provider is located and approved

12. How to file an appeal

13. TennCare Medical Appeal Form http://tennessee.gov/tenncare/forms/ medappeal.pdf

21. Withdrawing appeal: • Recipient, ISC or Legal Representative • If hearing not scheduled, must be in writing • If hearing is scheduled, should be withdrawn through LSU • Withdrawal form (RO or LSU)

22. 1. Sign this page ONLY if you want to end your TennCare appeal. If you want to end your TennCare appeal and do not want a TennCare hearing, you must sign and get this page to TennCare by [date]. TennCare will send this page to the Judge to cancel your hearing. This means your appeal will end. I want to end my TennCare appeal. I do not want a fair hearing. Name: ________________ Hearing date: ______________________ APD Docket Number:09.03-xxxxxxx To end your appeal, sign your name here:__________________ Date:_________________

23. 2. Mail or fax the signed page to TennCare. There are 2 ways to get your signed page to TennCare. 1. Mail this page to: Bureau of TennCare Legal Solutions Unit 310 Great Circle Road Nashville, Tennessee 37243 2. Or, fax this page to: 1-888-345-5575 If you have questions about your hearing, call the Legal Solutions Unit at 1-877-778-3698.

24. Pamela Romer, Appeals Director, MTRO (615) 231-5031 Lori Shelton, Appeals Director, ETRO (865) 588-0508, ext. 239 Libby Taylor, Appeals Director, WTRO (901) 745- 7327 Jon Hamrick, Director of Medicaid Affairs, CO (615) 253-8734