Key Provisions of Grier: Ensuring Due Process Rights
The key provisions of Grier, focusing on appeal rights, compliance requirements, and due process additions. Learn when Grier applies, what constitutes an adverse action, and provider responsibilities. Understand the significance of expedited appeals and the scenarios where Grier does not apply."
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Presentation Transcript
Grier Revised Consent Decree September 2015
Origins of Grier 1979 - Daniels vs. White 1994 TennCare August 1, 2000 - Grier Revised Consent Decree Due process additions- 2003 Agreed Order- vacated June 17, 2015
Key Provisions of Grier Appeal rights of persons served Compliance requirements Appeal must be filed within 30 days Filed by person or on their behalf Timing/types of appeals
Expedited Appeal constitutes an emergency Person s life Person s physical/mental health Person s ability to attain, regain, or maintain full function
Key Provisions of Grier Outlines Due Process requirements Compliance requirements Appeal rights Appeal must be filed within 30 days Timing/types of appeals
Grier applies when: 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).
An adverse action is Denial Delay Termination Suspension Reduction Any act, or failure to act that impacts the quality, availability, or timeliness of a Medicaid waiver service to an eligible person.
Grier does not apply when: State-funded services are denied Person is on the waiting list -not enrolled to receive Medicaid services Services provided without prior authorization- no FFP Dispute over rate for service
Provider Responsibilities: Educate Staff Provide adequate network Provide services as authorized Provide services consistently and timely
Provider Responsibilities: Regional office must be informed immediately upon any provide-initiated adverse action The Regional Office must be informed a minimum of 60 days before ceasing to provide services Services must continue until a new provider is located and approved Failure may result in sanctions or recoupment of funds by DIDD
How to file an appeal
You can file an appeal by Mailing: TennCare Solutions Unit P. O. Box 000593 Nashville, TN 37202-0593 Calling/Faxing The phone number is 1-800-878-3192 and the FAX number is 1-888- 345-5575 Appeal Page: Go to tn.gov/tenncare. Click For Members/Applicants then click on How to file a medical appeal . Or, to have TennCare mail you an appeal page, call them for free at 1- 800-878-3192.
Withdrawing appeal: Person, ISC or Legal Representative If hearing not scheduled, must be in writing If hearing is scheduled, withdraw through TennCare Legal Solutions Unit
Appeals Directors Central Jon Hamrick (615) 253-8734 East Lori Shelton (865) 594-9299 Middle Deborah Ball (615) 884-6090 West Libby Taylor (901) 745-7327
