This chapter shall be known and may be cited as the “Tennessee Health Carrier Grievance and External Review Procedure Act.” The purpose of this chapter is to provide standards for the establishment and maintenance of procedures by health carriers to assure that covered persons and healthcare providers have the opportunity for the appropriate resolution of […]
For purposes of this chapter, unless the context otherwise requires: “Adverse determination” means: A determination by a health carrier or its designee utilization review organization that, based upon the information provided, a request for a benefit under the health carrier’s health benefit plan does not meet the health carrier’s requirements for medical necessity, appropriateness, healthcare […]
Except as otherwise specified, this chapter shall apply to all health carriers. This chapter shall not apply to a policy or certificate that provides: Coverage only for a specified disease, specified accident or accident-only coverage, credit, dental, disability income, hospital indemnity, long-term care insurance, as defined by § 56-42-103, vision care or any other limited […]
Nothing in this chapter shall limit or restrict the health carrier from denying coverage on the grounds that the services are determined not to be medically necessary.
A health carrier shall maintain written records to document all grievances received during a calendar year. The register shall be maintained in a manner that is reasonably clear and accessible to the commissioner. A request for a first level review of a grievance involving an adverse determination shall be processed in compliance with § 56-61-107 […]
Except as specified in § 56-61-109, a health carrier shall use written procedures for receiving and resolving grievances from aggrieved persons, as provided in §§ 56-61-107 and 56-61-108, unless otherwise provided by this chapter. A health carrier shall file with the commissioner a copy of the procedures required under subsection (a), including all forms used […]
Within one hundred and eighty (180) days after the date of receipt of a notice of an adverse determination, an aggrieved person may file a grievance with the health carrier requesting a first level review of the adverse determination. The health carrier shall provide the aggrieved person with the name and address of the organizational […]
A health carrier shall establish a second level review process to give aggrieved persons, who are dissatisfied with the first level review decision, the option of requesting a second level review. Health carriers required by this section to establish a second level review process shall provide aggrieved persons with notice pursuant to § 56-61-107, as […]
A health carrier shall establish written procedures for the expedited review of urgent care requests of grievances involving an adverse determination. In addition to subsection (a), a health carrier shall provide expedited review of a grievance involving an adverse determination with respect to concurrent review of urgent care requests involving an admission, availability of care, […]
The commissioner may, after notice and hearing, promulgate reasonable rules and regulations to carry out this chapter. Such rules and regulations shall be subject to review in accordance with the Uniform Administrative Procedures Act, compiled in title 4, chapter 5.
A person that violates this chapter shall be subject to the penalties set forth in § 56-2-305.
For purposes of this section, “approved entity” means: The utilization review accreditation commission (URAC); or Other nationally recognized private accrediting entity employing standards for the accreditation of external review programs that the commissioner deems are substantially equivalent to the standards for conducting an external review pursuant to §§ 56-61-113 — 56-61-118. A health carrier may […]
A health carrier shall notify the aggrieved person in writing of the right to request an external review to be conducted pursuant to §§ 56-61-116 and 56-61-118 and include the appropriate statements and information set forth in subsection (b) at the same time that the health carrier sends written notice of a final adverse determination. […]
Except for a request for an expedited external review as set forth in § 56-61-117 or § 56-61-118(n), all requests for external review shall be made in writing to the health carrier. Unless otherwise set forth by this chapter, an aggrieved person may file a request for external review after the receipt of a final […]
Except as provided in subsection (b), a request for an external review pursuant to § 56-61-116 or § 56-61-118 shall not be made until the aggrieved person has exhausted the health carrier’s internal grievance process as set forth in this chapter. An aggrieved person shall be considered to have exhausted the health carrier’s internal grievance […]
Within six (6) months after the date of receipt of a notice of an adverse determination or final adverse determination pursuant to § 56-61-113, an aggrieved person may file a request for an external review with the health carrier. Within ten (10) business days following the date of receipt of the copy of the external […]
Except as provided in subsection (f), an aggrieved person may make a request for an expedited external review with the health carrier at the time the aggrieved person receives: An adverse determination if: The adverse determination involves a medical condition of the covered person for which the timeframe for completion of an expedited internal review […]
Within six (6) months after the date of receipt of a notice of an adverse determination or final adverse determination that involves a denial of coverage based on a determination that the healthcare service or treatment recommended or requested is investigational, an aggrieved person may file a request for external review with the health carrier. […]
An external review decision is binding on the health carrier except to the extent that the health carrier has other remedies available under applicable federal or state law. An external review decision is binding on the covered person except to the extent that the covered person has other remedies available under applicable federal or state […]
The commissioner shall approve external review organizations eligible to conduct external reviews under this chapter. In order to be eligible for approval by the commissioner to conduct external reviews under this chapter, an external review organization: Except as otherwise provided in this section, shall be accredited by a nationally recognized private accrediting entity that the […]
