What are my Child’s TennCare Service Appeal Rights?
Does your child have TennCare? Then TennCare must pay for all the health care that is medically necessary for your child.
TennCare only pays if the care is:
- Ordered by a doctor, and
- Needed to find out what’s wrong or to treat it, and
- Safe and it works (effective), and
- Not an experiment, and
- The cheapest care that is enough (adequate).
When someone’s care meets these rules, TennCare calls it medically necessary. Most of the time, if the doctor* orders the care, your child gets it. For some types of care, the doctor will need to get TennCare’s OK first. Your health plan or mental health plan will look at the care the doctor is asking for. The health plan will OK or say NO to the care. Sometimes the health plan will talk to your child’s doctor to find out why the care is needed. What if TennCare says this care is not covered? Your child has a right to it if he or she needs it.
What if TennCare won’t pay for the care?
It might be because the doctor needed to get TennCare’s OK for the care first. If he didn’t get TennCare’s OK first, they may say no to the care.
Does TennCare want to stop or change the care your child gets? Does TennCare plan to say “no” to new care?
Then TennCare must tell you in writing first. Is the care a new service? Then TennCare has up to 21 days to decide if you can get the care. They also must tell you if there will be a delay in getting the care. Is your child already getting the care? Then TennCare must tell you at least 30 days before they stop or cut the care or stop paying.
Want to keep getting the care during the appeal?
Then you must appeal within 10 days of getting TennCare’s letter changing the care. Has the care already stopped? Then you can ask TennCare to start it again while the appeal is being decided. Be sure to say you want to keep getting the care.
Your child can’t get care during the appeal IF:
- The care is called “non-covered” by TennCare.
TennCare must write you before it changes, stops or says “no” to care. TennCare MUST write you saying:
- What kind of care it is and how much your child gets, and
- Who ordered the care, and
- Why the care was denied, changed, or stopped, and
- Who helped the health plan decide, and
- What medical records were used to decide, and
- Why the care is not covered or not needed, and
- How to appeal.
