§ 56-60-105. Granting a Third Party Access to a Provider’s Health Care Services and Contractual Discounts Pursuant to a Provider Network Contract
A contracting entity shall only grant access to a provider’s health care services and contractual discounts pursuant to the contracting entity’s provider network contract if: The provider network contract clearly and plainly authorizes the contracting entity to enter into an agreement with a third party allowing the third party to exercise the contracting entity’s rights […]
§ 56-60-106. Subsequent Grants of Access to Another Third Party
Any third party, having itself been granted access to a provider’s health care services and contractual discounts pursuant to a provider network contract, that subsequently grants access to another third party, is obligated to comply with the rights and responsibilities imposed on contracting entities under §§ 56-60-104 and 56-60-105. Any third party that enters into […]
§ 56-60-107. Requirements for Granting a Third Party Access to the Contracting Entity’s Provider Network — Refusal to Accept Contractual Discount
No contracting entity shall grant a third party access to the contracting entity’s provider network contract by lease, rent or by any other means unless the third party accessing the provider network contract is: A payer of claims or a third party administrator or other entity that administers or processes claims on behalf of the […]
§ 56-60-108. Enforcement — Rules
The department shall enforce this chapter. The department is authorized to promulgate rules to effectuate this chapter in accordance with the Uniform Administrative Procedures Act, compiled in title 4, chapter 5. The initial rules promulgated by the department may be designated as emergency rules if the department finds that it cannot implement the rules by […]
§ 56-60-109. Unfair Insurance Practice — Complaints for Violations
It is an unfair insurance practice for the purposes of the Tennessee Unfair Trade Practices and Unfair Claims Settlement Act of 2009, compiled in chapter 8, part 1 of this title, to knowingly access a provider’s services or exercise a provider’s contractual discounts pursuant to a provider network contract if the access or exercise is […]
§ 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 […]