(a) 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.

Terms Used In Tennessee Code 56-61-105

  • Adverse determination: means :
    (A) 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 setting, level of care or effectiveness and the requested benefit is therefore denied, reduced or terminated or payment is not provided or made, in whole or in part, for the benefit. See Tennessee Code 56-61-102
  • Aggrieved person: means :
    (A) A healthcare provider. See Tennessee Code 56-61-102
  • Commissioner: means the commissioner of commerce and insurance. See Tennessee Code 56-61-102
  • Covered person: means a policyholder, subscriber, enrollee or other individual participating in a health benefit plan. See Tennessee Code 56-61-102
  • Grievance: means a written appeal of an adverse determination or final adverse determination submitted by or on behalf of a covered person regarding:
    (A) Availability, delivery or quality of healthcare services regarding an adverse determination. See Tennessee Code 56-61-102
  • Health benefit plan: means a policy, contract, certificate or agreement offered or issued by a health carrier to provide, deliver, arrange for, pay for or reimburse any of the costs of healthcare services. See Tennessee Code 56-61-102
  • Health carrier: means an entity subject to the insurance laws and regulations of this state, or subject to the jurisdiction of the commissioner, that contracts or offers to contract to provide, deliver, arrange for, pay for or reimburse any of the costs of healthcare services, including a sickness and accident insurance company, a health maintenance organization, a nonprofit hospital and health service corporation, or any other entity providing a plan of health insurance, health benefits or healthcare services. See Tennessee Code 56-61-102
  • provider: means a healthcare professional or a facility. See Tennessee Code 56-61-102
  • Register: means the written records kept by a health carrier to document all grievances received during a calendar year. See Tennessee Code 56-61-102
  • written: includes printing, typewriting, engraving, lithography, and any other mode of representing words and letters. See Tennessee Code 1-3-105
  • Year: means a calendar year, unless otherwise expressed. See Tennessee Code 1-3-105
(b) A request for a first level review of a grievance involving an adverse determination shall be processed in compliance with § 56-61-107 and is required to be included in the health carrier’s register.
(c) A request for a second level review of a grievance involving an adverse determination that may be conducted pursuant to § 56-61-108 shall be included in the health carrier’s register.
(d) For each grievance, the register shall contain, at a minimum, the following information:

(1) A general description of the reason for the grievance;
(2) The date the grievance was received;
(3) The date of each review or, if applicable, review meeting;
(4) The resolution at each level of the grievance, if applicable;
(5) The date of resolution at each level, if applicable; and
(6) The name of the aggrieved person for whom the grievance was filed.
(e)

(1) A health carrier shall retain the register compiled for a calendar year for the shorter of five (5) years or until the commissioner has adopted a final report of an examination that contains a review of the register for such calendar year.
(2)

(A) A health carrier shall submit to the commissioner, at least annually, a report in the format specified by the commissioner.
(B) The report shall include for each type of health benefit plan offered by the health carrier:

(i) The number of covered lives that fall under this chapter’s protections;
(ii) The total number of grievances;
(iii) The number of grievances for which a covered person and healthcare provider requested a second level voluntary grievance review pursuant to § 56-61-108;
(iv) The number of grievances resolved at each level, if applicable, and their resolution; and
(v) A synopsis of actions being taken to correct problems identified.
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