§ 56-61-101. Short Title — Purpose
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 […]
§ 56-61-102. Chapter Definitions
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 […]
§ 56-61-103. Applicability and Scope
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 […]
§ 56-61-104. No Limitations or Restrictions on Denying Coverage of Services Not Medically Necessary
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.
§ 56-61-105. Maintenance of Register of Written Records to Document Grievances
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 […]