(a) 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.
Terms Used In Tennessee Code 56-61-116
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
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
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.
External review organization: means an entity that conducts independent external reviews of adverse determinations and final adverse determinations of a health carrier. See Tennessee Code 56-61-102
Final adverse determination: means an adverse determination involving a covered benefit that has been upheld by a health carrier at the completion of the health carrier's internal grievance process procedures as set forth in this chapter. 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
Healthcare professional: means a physician or other healthcare practitioner licensed, accredited or certified to perform specified healthcare services consistent with state law. See Tennessee Code 56-61-102
Healthcare services: means services for the diagnosis, prevention, treatment, cure or relief of a health condition, illness, injury or disease. See Tennessee Code 56-61-102
Medical or scientific evidence: means evidence found in the following sources. 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
Retrospective review: means any review of a request for a benefit that is not a prospective review request. See Tennessee Code 56-61-102
United States: includes the District of Columbia and the several territories of the United States. See Tennessee Code 1-3-105
Uphold: The decision of an appellate court not to reverse a lower court decision.
written: includes printing, typewriting, engraving, lithography, and any other mode of representing words and letters. See Tennessee Code 1-3-105
(b) Within ten (10) business days following the date of receipt of the copy of the external review request, the health carrier shall complete a preliminary review of the request to determine whether:
(1) The individual is or was a covered person in the health benefit plan at the time that the healthcare service was requested or, in the case of a retrospective review, was a covered person in the health benefit plan at the time that the healthcare service was provided;(2) The healthcare service that is the subject of the adverse determination or the final adverse determination is a covered service under the covered person’s health benefit plan;(3) The covered person has exhausted the health carrier’s internal grievance process as set forth in this chapter unless the covered person is not required to exhaust the health carrier’s internal grievance process pursuant to § 56-61-115; and(4) The covered person has provided all the information and forms required to process an external review, including the release form provided pursuant to § 56-61-113.(c) Within three (3) business days after completion of the preliminary review, the health carrier shall notify the aggrieved person in writing whether:
(1) The request is complete; and(2) The request is eligible for external review.(d) If the request set out in subsection (a):
(1) Is not complete, the health carrier shall notify the aggrieved person in writing and include in the notice what information or materials are needed to make the request complete; or(2) Is not eligible for external review, the health carrier shall notify the aggrieved person in writing and include in the notice the reasons for its ineligibility.(e) The notice of initial determination shall include a statement informing the aggrieved person that a health carrier’s initial determination that the external review request is ineligible for review may be appealed to the commissioner.(f) The commissioner may determine that a request is eligible for external review under this chapter notwithstanding a health carrier’s initial determination that the request is ineligible and require that it be referred for external review.
(1) In making a determination under this subsection (f), the commissioner’s decision shall be made in accordance with the terms of the covered person’s health benefit plan and shall be subject to all applicable provisions of this chapter.(2) Whenever the health carrier or commissioner determines that a request is eligible for external review following the preliminary review conducted pursuant to subdivision (c)(2), within three (3) business days after the determination by the health carrier or within three (3) business days after the date of receipt of the determination by the commissioner, the health carrier shall notify the aggrieved person in writing of the request’s eligibility and acceptance for external review.(g) The health carrier shall include in the notice provided to the aggrieved person, a statement that additional information may be submitted in writing to the external review organization within six (6) business days following the date of receipt of the notice provided pursuant to subdivision (f)(2), and that the external review organization shall consider such additional information when conducting the external review. The external review organization is not required to, but may, accept for consideration such additional information submitted by the aggrieved person after six (6) business days. The external review organization shall forward to the health carrier any information received from an aggrieved person no later than one (1) business day after the date the information is received by the external review organization.(h) Within six (6) business days after the date of receipt of the notice provided pursuant to subsection (g), the health carrier shall provide to the external review organization any documents and information considered in making the adverse determination or final adverse determination.
(1) Failure by the health carrier to provide the documents and information within the time specified in this subsection (h) shall not delay the external review.(2) If the health carrier fails to provide the documents and information within the time specified in this subsection (h), the external review organization may terminate the external review and make a decision to reverse the adverse determination or final adverse determination.(3) The external review organization shall notify the health carrier within one (1) business day of its decision to reverse the adverse determination or final adverse determination pursuant to subdivision (h)(2). The health carrier shall notify the aggrieved person within three (3) business days of the external review organization’s decision.(i) The external review organization shall review all of the information and documents received within six (6) business days pursuant to subsection (g) and any other information submitted in writing by the aggrieved person.(j) Upon receipt of the information required to be forwarded pursuant to subsection (g), the health carrier may reconsider its final adverse determination that is the subject of the external review.
(1) Reconsideration by the health carrier of its final adverse determination shall not delay or terminate the external review.(2) The external review may only be terminated by the health carrier if the health carrier decides, upon completion of its reconsideration, to reverse its final adverse determination and provide coverage or payment for the healthcare service that is the subject of the adverse determination or final adverse determination. If the health carrier reverses its previous determinations pursuant to this subsection (j), the health carrier shall not at a later date reverse its reversal.(3) Within three (3) business days after making the decision to reverse its adverse determination or final adverse determination, the health carrier shall notify the aggrieved person and the external review organization in writing of its decision. The external review organization shall terminate the external review upon receipt of the notice from the health carrier sent pursuant to this subdivision (j)(3).(k) In addition to the documents and information provided pursuant to subsections (g) and (h), the external review organization, to the extent that the information or documents are available and the external review organization considers them appropriate, shall consider the following in reaching a decision:
(1) The covered person’s pertinent medical records;(2) The attending healthcare professional‘s recommendation;(3) The consulting reports from appropriate healthcare professionals and other documents submitted by the aggrieved person or the covered person’s treating physician or healthcare professional;(4) The terms of coverage under the covered person’s health benefit plan with the health carrier to ensure that the external review organization’s decision is not contrary to the terms of coverage under the covered person’s health benefit plan with the health carrier;(5) Any applicable clinical review criteria developed and used by the health carrier;(6) The most appropriate practice guidelines, which shall include applicable medical or scientific evidence based standards;(7) Findings, studies or research conducted by or under the auspices of federal government agencies and nationally recognized federal research institutes, including:
(A) The agency for healthcare research and quality;(B) The national institutes of health;(C) The national cancer institute;(D) The national academy of sciences;(E) The centers for medicare & medicaid services;(F) The federal food and drug administration; and(G) Any national board recognized by the national institutes of health for the purpose of evaluating the medical value of healthcare services; and(8) The opinion of the external review organization’s clinical reviewer or reviewers after considering subdivisions (k)(1)-(7), to the extent the information or documents are available and the clinical reviewer or reviewers consider appropriate.(l) In reaching a decision, the external review organization is not bound by any decisions or conclusions reached during the health carrier’s internal grievance process as set forth in this chapter. However, the external review organization shall be bound by the terms and conditions of the covered person’s health benefit plan.(m) Within forty (40) days after the date of receipt of the request for an external review, the external review organization shall provide written notice of its decision to uphold or reverse the adverse determination or the final adverse determination to the health carrier.(n) Within two (2) calendar days after rendering the decision under subsection (m), the external review organization shall notify the health carrier. Within three (3) calendar days after receiving the decision from the external review organization, the health carrier shall notify the aggrieved person of the external review organization’s decision to uphold or reverse the adverse determination or final adverse determination. If the decision involved healthcare provider compensation, the health carrier shall make appropriate payment to the healthcare provider within ten (10) business days of the receipt of a notice of the external review organization’s decision.(o) The external review organization shall include in the notice sent pursuant to subsection (m):
(1) A general description of the reason for the request for external review;(2) The date that the external review organization received the assignment from the health carrier to conduct the external review;(3) The date that the external review was conducted;(4) The date of the external review organization’s decision;(5) The principal reason or reasons for the external review organization’s decision, including any applicable, medical or scientific evidence based standards used as a basis for its decision;(6) The rationale for the external review organization’s decision; and(7) References to the evidence or documentation, including the medical or scientific evidence based standards, considered in reaching the external review organization’s decision.(p) Upon receipt of a notice of a decision pursuant to subsection (m) reversing the adverse determination or final adverse determination, the health carrier shall immediately approve the coverage that was the subject of the adverse determination or final adverse determination. If the decision involved healthcare provider compensation, the health carrier shall make appropriate payment to the healthcare provider within ten (10) business days of the receipt of a notice of the external review organization’s decision.(q) The health carrier, regardless of utilization review accreditation commission (URAC) accreditation, shall have a contract with at least two (2) or more external review entities and may give the aggrieved person the opportunity to select, from among the external review organizations that the health carrier has contracts with, the external review organization to conduct the review; provided, however, that the commissioner may require assignments of external review organizations on a random basis if such random assignment is required per the direction of the United Statesdepartment of health and human services. The commissioner is hereby granted emergency rulemaking authority to implement random assignments pursuant to this subsection (q).
