TJC Referral:
TennCare Problems Following Delay Appeals
Complete this form for any TennCare enrollment problems after delay appeals. Fax to TJC at
(615)255-0354
Please enter each person in the household, and indicate who was on the application.
Full Name
Relationship to primary
SSN
contact (e.g., child,
sibling, parent)
Primary client
DOB
On
Application?
Household income as reported on CoverKids or Marketplace application ______________________________
Are all applicants U.S. citizens? Y/N
If no, note immigration status and time they have held that status:
Date of Marketplace Application (Include all if there are multiple.): _________________
Application ID number: _________________________
(Please attach Eligibility Notice if you have it)
Date of delay appeal (Include all if there are multiple.): ________________
(Please attach any proof of delay appeal if you have it)
Was proof of application submitted to the state with the delay appeal? Y / N (circle one)
Please check all that apply:
 Applicant still does not have a decision 45/90 days after delay appeal
 Applicant has had no follow-up from TennCare after delay appeal
 Applicant has received notice(s) requesting proof of income since filing delay appeal
Did applicant submit proof of income? Y / N If no, why not? ______________________
 Applicant has received notice(s) requesting proof of application since filing delay appeal
Did applicant submit proof of application? Y / N If no, why not? ___________________
 Applicant has received notice(s) requesting proof of citizenship/immigration status since
filing delay appeal
Did applicant submit proof of status? Y / N If no, why not? ___________________
 Applicant was denied after delay appeal. Reason for denial:
 Information not received within 10 days
 Not eligible: income
 Not eligible: category
 Not eligible: citizenship/immigration status
 Applicant was approved after delay appeal, but start date is wrong
Current coverage start date: _____________
 Other: _________________________________________________________________________
Please attach any correspondence received from TennCare, CoverKids or the Marketplace
following delay appeal
Fax this form to the Tennessee Justice Center at (615) 255-0354 to
Attn: Marysa LaRowe