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Posted by: Chandra Williams on Nov 5, 2015

Court: TN Supreme Court

Attorneys 1:

J. Mark Tipps, John C. Hayworth, and Erin Palmer Polly, Nashville, Tennessee, for the appellant, UnitedHealthcare Plan of the River Valley, Inc., d/b/a AmeriChoice.

Attorneys 2:

Herbert H. Slatery, III, Attorney General and Reporter; Andre´e S. Blumenstein, Solicitor General; Linda A. Ross, Deputy Attorney General; Carolyn E. Reed, Assistant Attorney General; and Sue A. Sheldon, Senior Counsel, for the intervenor-appellant, Tennessee Attorney General. Steven A. Riley and James N. Bowen, Nashville, Tennessee, for the appellee, The Chattanooga-Hamilton County Hospital Authority, d/b/a Erlanger Health System. OPINION

Judge(s): KIRBY

We granted permission to appeal to address whether exhaustion of administrative remedies is required in this lawsuit brought by a hospital against a TennCare managed care organization (MCO). The hospital alleged in its complaint that the MCO had not paid the hospital all of the monies due for emergency services provided to the MCO?s TennCare enrollees. In its answer, the MCO asserted that it had paid the hospital in accordance with TennCare regulations; the MCO also filed a counterclaim regarding overpayments made pursuant to the TennCare regulations. The MCO filed a motion for partial summary judgment. It argued that the hospital?s allegations implicitly challenged the applicability and/or validity of the TennCare regulations, so the Uniform Administrative Procedures Act (UAPA) required the hospital to exhaust its administrative remedies by bringing those issues to TennCare prior to filing suit. Absent exhaustion of administrative remedies, the MCO argued, the trial court was without subject matter jurisdiction to hear the case. The trial court agreed; it dismissed the hospital?s lawsuit for lack of subject matter jurisdiction and dismissed the MCO?s counterclaim as well. The Court of Appeals reversed; it concluded that the hospital?s lawsuit was simply a dispute regarding the interpretation of statutes and regulations, over which the trial court had jurisdiction. The MCO appeals. Looking at the substance of the parties? dispute rather than simply the face of the hospital?s complaint, we hold that the UAPA requires exhaustion of administrative remedies in this matter to the extent that resolution of the parties? claims would necessarily require the trial court to render a declaratory judgment concerning the validity or applicability of TennCare regulations. While the UAPA 1 ?? prohibits the trial court from rendering such declaratory relief absent exhaustion of administrative remedies, it does not address claims for damages. In this case, both parties have asserted damage claims that hinge on the issues to be addressed in the administrative proceedings. Under these circumstances, we reverse the dismissal of the complaint and the counterclaim and remand the case to the trial court with directions to hold the parties? damage claims in abeyance pending resolution of administrative proceedings regarding the validity or applicability of the TennCare regulations at issue.