What if medical necessity is denied?

If TMHP determines that the person does not have medical necessity, TMHP will notify the attending physician and the nursing facility and provide them an opportunity to present additional medical information. If neither the attending physician nor the nursing facility physician responds or contests TMHP’s findings within 10 business days, the findings are final. If, however, the attending physician or the nursing facility physician contests TMHP’s findings, at least one physician with TMHP must review the case. If upon this second review, TMHP’s physician determines that the person does not have medical necessity, the determination becomes final. Notice of a final determination of denied medical necessity is then sent to the attending physician, the nursing facility and the person (or responsible party).

After a person receives written notice of TMHP’s final determination, the person or responsible party must request a fair hearing within 90 days to appeal the medical necessity denial. If the request for hearing is made within 10 days of the notice of denied medical necessity, nursing home care services will continue to be paid by the state for up to 10 days following the hearing officer’s written decision. If the request for a hearing is not made within 10 days of the notice of denied medical necessity, the state will continue making payments to the nursing facility for 15 days or until the person is discharged, whichever occurs first. If the person fails to request a fair hearing within 90 days of the denied medical necessity, the person loses the right to appeal the decision.

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