(a) Except as provided in subsection (f), an aggrieved person may make a request for an expedited external review with the health carrier at the time the aggrieved person receives:
Terms Used In Tennessee Code 56-61-117
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
Complaint: A written statement by the plaintiff stating the wrongs allegedly committed by the defendant.
Covered person: means a policyholder, subscriber, enrollee or other individual participating in a health benefit plan. See Tennessee Code 56-61-102
Emergency services: means healthcare items and services furnished or required to evaluate and treat an emergency medical condition. 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
Facility: means an institution licensed under title 68 providing healthcare services or a healthcare setting, including but not limited to, hospitals and other licensed inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers, diagnostic, laboratory and imaging centers, and rehabilitation. 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
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
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
(1) An adverse determination if:
(A) The adverse determination involves a medical condition of the covered person for which the timeframe for completion of an expedited internal review of a grievance involving an adverse determination set forth in § 56-61-109 would seriously jeopardize the life or health of the covered person or would jeopardize the covered person’s ability to regain maximum function; and(B) The aggrieved person has filed a request for an expedited review of a grievance involving an adverse determination as set forth in § 56-61-109; or(2) A final adverse determination:
(A) If the covered person has a medical condition where the timeframe for completion of a standard external review pursuant to § 56-61-116 would seriously jeopardize the life or health of the covered person or would jeopardize the covered person’s ability to regain maximum function; or(B) If the final adverse determination concerns an admission, availability of care, continued stay or healthcare service for which the covered person received emergency services, but has not been discharged from a facility.(b)(1) Immediately upon receipt of the request, the health carrier shall determine whether the request meets the reviewability requirements set forth in § 56-61-116. The health carrier shall immediately notify the aggrieved person of its eligibility determination regarding the availability of external review.(2) The notice of initial determination shall include a statement informing the aggrieved person that a health carrier’s initial determination that an external review request is ineligible for review and that the aggrieved person may file a complaint with the commissioner.
(A) The commissioner may determine that a request is eligible for external review notwithstanding a health carrier’s initial determination that the request is ineligible and that it be referred to external review.(B) In making a determination under subdivision (b)(2)(A), 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.(c) Upon making a determination that a request is eligible for expedited external review, the health carrier shall immediately notify the aggrieved person in writing that the request is eligible for external review.(d) At the same time, the health carrier shall immediately notify the external review organization and provide or transmit all necessary documents and information considered when making the adverse determination or final adverse determination electronically or by telephone, facsimile or any other expeditious method available.(e) In addition to the documents and information provided or transmitted pursuant to subsection (d), 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) Consulting reports from appropriate healthcare professionals and other documents submitted by the health carrier or the aggrieved person;(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) The most appropriate practice guidelines, which shall include medical or scientific evidence based standards;(6) Applicable clinical review criteria developed and used by the health carrier in making adverse determinations;(7) Findings, studies or research conducted by or under the auspices of federal government agencies and nationally recognized federal research institutes, including:
(A) The federal 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 (e)(1)-(7) to the extent that the information and documents are available and the clinical reviewer or reviewers consider appropriate.(f)(1)(A) As expeditiously as the covered person’s medical condition or circumstances requires, but in no event more than seventy-two (72) hours after the date of receipt of the request for an expedited external review that meets the reviewability requirements, the external review organization shall make a decision to uphold or reverse the adverse determination or final adverse determination; and(B) Notify the health carrier of the decision and the health carrier must immediately notify the aggrieved person of the external review organization’s decision. The aggrieved person must receive the decision of the expedited external review within seventy-two (72) hours after the date of receipt of the request for expedited external review.(2)(A) If the notice provided pursuant to subdivision (f)(1) was not in writing, within forty-eight (48) hours after the date of providing such notice, the external review organization shall provide written confirmation of the decision to the health carrier; and include the information set forth in this section.(B) The health carrier shall immediately notify the aggrieved person of the external review organization’s decision and include the information set forth in this section.(C) Upon receipt of notice of the decision rendered pursuant to subdivision (f)(1) 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 the final adverse determination.(g) An expedited external review shall not be provided for retrospective adverse determinations or final adverse determinations.
