(a) 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.
Terms Used In Tennessee Code 56-61-108
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
Answer: The formal written statement by a defendant responding to a civil complaint and setting forth the grounds for defense.
Attorney: means the person designated and authorized by subscribers as the attorney-in-fact having authority to obligate them on reciprocal insurance contracts. See Tennessee Code 56-16-102
Authorized representative: means :(A) A person to whom a covered person has given express written consent to represent the covered person for purposes of this chapter. See Tennessee Code 56-61-102
benefits: means those healthcare services to which a covered person is entitled under the terms of a health benefit plan. See Tennessee Code 56-61-102
Clinical review criteria: means the written screening procedures, decision abstracts, clinical protocols and practice guidelines used by the health carrier to determine the medical necessity and appropriateness of healthcare services. 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
Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
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 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
Person: means an individual, a corporation, a partnership, an association, a joint venture, a joint stock company, a trust, an unincorporated organization, any similar entity or any combination of the entities listed in this subdivision (28). See Tennessee Code 56-61-102
Representative: when applied to those who represent a decedent, includes executors and administrators, unless the context implies heirs and distributees. See Tennessee Code 1-3-105
written: includes printing, typewriting, engraving, lithography, and any other mode of representing words and letters. See Tennessee Code 1-3-105
(b)(1) 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 appropriate, of the option to file a request with the health carrier for a second level review of the first level review’s decision rendered pursuant to § 56-61-107.(2) Upon receipt of a request for a second level review, the health carrier shall send notice within five (5) business days to the covered person or, if applicable, the covered person‘s authorized representative of the covered person’s right to:
(A) Request, within the timeframe specified in subdivision (b)(3)(A), the opportunity to appear in person before a review panel of the health carrier’s designated representatives;(B) Receive from the health carrier, upon request, copies of all documents, records and other information that is not confidential or privileged relevant to the covered person’s request for benefits;(C) Present the covered person’s case to the review panel;(D) Submit written comments, documents, records and other material relating to the request for benefits to the review panel for consideration when conducting the second level review both before and, if applicable, during the second level review;(E) If applicable, ask questions of any representative of the health carrier on the review panel; provided, such questions are governed and relevant to the subject matter of the second level review; and(F) Be assisted or represented by an individual of the covered person’s choice, at the expense of such covered person.(3)(A) A covered person or covered person’s authorized representative wishing to request to appear in person before the review panel of the health carrier’s designated representatives shall make the request to the health carrier within ten (10) business days after the date of receipt of the notice sent in accordance with subdivision (b)(2).(B) The covered person’s right to a fair review shall not be made conditional on the covered person or the covered person’s authorized representative’s appearance at the second level review.(4) Upon receipt of a request for a second level review, the health carrier shall send notice within five (5) business days to the healthcare provider of the healthcare provider’s right to:
(A) Receive from the health carrier, upon request, copies of all documents, records and other information that is not confidential or privileged relevant to the aggrieved person‘s request for benefits;(B) Submit written comments, documents, records and other material relating to the request for benefits for the review panel to consider when conducting the second level review; and(C) If applicable, ask questions of any representative of the health carrier on the review panel; provided, such questions are governed and relevant to the subject matter of the second level review.(c)(1)(A) With respect to a second level review of a first level review decision rendered pursuant to § 56-61-107, a health carrier shall appoint a review panel to review the request.(B) In conducting the review, the review panel shall take into consideration all comments, documents, records and other information regarding the request for benefits submitted by the aggrieved person pursuant to subdivision (b)(2), without regard to whether the information was submitted or considered in reaching the first level review’s decision.(C) The review panel shall have the legal authority to bind the health carrier to the review panel’s decision.(2)(A) Except as provided in subdivision (c)(2)(B), a majority of the review panel shall be comprised of individuals who were not involved in the first level review decision rendered pursuant to § 56-61-107.(B) An individual who was involved with the first level review decision may be a member of the review panel or appear before the review panel to present information or answer questions.(C) The health carrier shall ensure that the individuals conducting the second level review of the first level review decision have appropriate expertise or have access to appropriate expertise that consists of similar knowledge and training or specialty that typically is involved in managing the medical condition, procedure or treatment that is the subject of the grievance under second level review.(D) No member of the review panel shall have a direct financial interest in the outcome of the second level review.(d) The procedures for conducting the second level review shall include the provisions described in subdivisions (d)(1)-(5):
(1) The review panel shall schedule and hold the second level review within sixty (60) business days after the date of receipt of the request for a second level review;
(A) The aggrieved person shall be notified in writing at least fifteen (15) business days in advance of the date of the second level review;(B) The health carrier shall not unreasonably deny a request for postponement of the second level review made by the aggrieved person;(2) The second level review shall be held during regular business hours at a location that meets the guidelines established by the Americans with Disabilities Act ( 42 U.S.C. § 1201 et seq.), to the aggrieved person;(3) In cases where an in-person second level review is not practical for geographic reasons, or any other reason, a health carrier shall offer the aggrieved person the opportunity to communicate with the review panel, at the health carrier’s sole expense, by conference call or other appropriate technology as determined by the health carrier;(4) The review panel shall provide the aggrieved person notice of the right to have an attorney present at the second level review; and(5) The review panel shall issue a written or electronic decision, as provided in subsection (e), to the aggrieved person within five (5) business days of completing the second level review meeting.(e) A decision issued pursuant to this section shall include the:
(1) Titles and qualifying credentials of the reviewers on the review panel;(2) Statement of the review panel’s understanding of the nature of the grievance and all pertinent facts;(3) Rationale for the review panel’s decision;(4) Reference to evidence or documentation considered by the review panel in rendering its decision; and(5) In cases concerning a grievance involving an adverse determination:
(A) Instructions for requesting a written statement of the clinical rationale, including the clinical review criteria used to make the determination; and(B) If applicable, a statement describing the procedures for obtaining an external review of the adverse determination pursuant to this chapter.
