An appeal is defined in BlueCare Tennessee's contract for TennCare services as an enrollee's (member's) right to contest verbally or in writing, any adverse action taken by the contractor (MCO) to deny, reduce, terminate, delay, or suspend a covered service as well as any other acts or omissions, which impair the quality, timeliness or availability of such benefits.Types of Appeals
- Expedited Appeal: Appeals may be expedited if the enrollee (member) requests a "fast" answer. Providers may file on the member’s behalf using the Provider’s Expedited Appeal Certificate.
- The Appeals Department must respond to these within 24 hours from the date received from TennCare Solutions.
- This is especially helpful if you will be at risk of serious health problems OR you might die if you do not get health care.
- Accelerated Appeal: An Accelerated Appeal is an appeal that was asked to be expedited but a review by BlueCare shows that you are not at risk of serious health problems OR you might die if you do not get health care.
- The Appeals Department must respond to Accelerated Appeals within 5 calendar days from the date received from TennCare Solutions.
- Standard Appeal: The Appeals Department must respond to these within 14 calendar days from the date received from TennCare Solutions.
Members (or their advocate) have the right to appeal if:
- TennCare says NO when the member asks for health care. [Denial]
- TennCare stops or changes the member's health care. [Reduction or Termination]
- Members have to wait too long to get health care. [Delay]
- Members have health care bills they think TennCare should have paid for, but didn't.
- Or there's some other reason members can't get health care when they need it.
Members also have the right to:
- Ask for an Expedited Appeal in an emergency situation.
- Ask that medical services continue during the appeal. [Continuation of Benefits: COB]
- All appeals are filed directly with the Bureau of TennCare (TennCare Solutions Unit-TSU, not BlueCare Tennessee), and may be filed 24 hrs a day, 7 days a week
- Members only have 30 days to appeal (10 days if you want to ask that medical services continue during the appeal).
- Usually, a member's appeal is decided within 90 days after the member files it.
- At the end of every member telephone call, our customer service representatives ask the following question: Are you satisfied with the outcome of this call and the service you received today?" This is to make sure that our members understand their appeal rights.
How Can Members File An Appeal?
Mail: Members can mail a completed appeal form or a letter about their problem to:
PO Box 593
Nashville, TN 37202-0593
The Form can also be found on our site.
Fax: Members can FAX (toll-free) a completed appeal form or letter about their problem to: 1-888-345-5575
Phone: Members can call (toll-free) TennCare Solutions: 1-800-878-3192; TTY/TDD 1-866-771-7043