(a) To be approved under § 56-61-120 to conduct external reviews, an external review organization shall have and maintain written policies and procedures that govern all aspects of both the standard external review process and the expedited external review process set forth in this chapter that include, at a minimum:
Terms Used In Tennessee Code 56-61-121
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
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
Contract: A legal written agreement that becomes binding when signed.
Covered person: means a policyholder, subscriber, enrollee or other individual participating in a health benefit plan. See Tennessee Code 56-61-102
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
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
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
State: when applied to the different parts of the United States, includes the District of Columbia and the several territories of the United States. See Tennessee Code 1-3-105
United States: includes the District of Columbia and the several territories of the United States. 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
(1) A quality assurance mechanism in place that:
(A) Ensures that external reviews are conducted within the specified timeframes and required notices are provided in a timely manner;(B) Ensures the selection of qualified and impartial clinical reviewers to conduct external reviews on behalf of the external review organization; suitable matching of reviewers to specific cases; and that the independent review organization employs or contracts with an adequate number of clinical reviewers to meet this objective;(C) Ensures the confidentiality of medical and treatment records and clinical review criteria; and(D) Ensures that any person employed by or under contract with the external review organization adheres to the requirements of this chapter;(2) A toll-free telephone service to receive information on a twenty-four-hour a day, seven-day a week basis related to external reviews that is capable of accepting, recording or providing appropriate instruction to incoming telephone callers during hours outside of normal business hours; and(3) Agree to maintain and provide to the commissioner the information set out in § 56-61-125.(b) All clinical reviewers assigned by an external review organization to conduct external reviews shall be physicians or other appropriate healthcare providers who meet the following minimum qualifications:
(1) Be an expert in the treatment of the covered person‘s medical condition that is the subject of the external review;(2) Be knowledgeable about the recommended healthcare service or treatment through recent or current actual clinical experience treating patients with the same or similar medical condition of the covered person;(3) Hold a nonrestricted license in a state of the United States and, for physicians, a current certification by a recognized American medical specialty board in the area or areas appropriate to the subject of the external review; and(4) Have no history of disciplinary actions or sanctions, including loss of staff privileges or participation restrictions, that have been taken or are pending by any hospital, governmental agency or unit, or regulatory body that raise a substantial question as to the clinical reviewer’s physical, mental or professional competence or moral character.(c) In addition to the requirements set forth in subsection (a), an external review organization may not own or control, be a subsidiary of or in any way be owned or controlled by, or exercise control with a health benefit plan, a national, state or local trade association of health benefit plans, or a national, state or local trade association of healthcare providers.(d) In addition to the requirements set forth in subsections (a), (b) and (c), to be approved pursuant to § 56-61-122 to conduct an external review of a specified case, neither the external review organization selected to conduct the external review nor any clinical reviewer assigned by the external organization to conduct the external review may have a material professional, familial or financial conflict of interest with any of the following:
(1) The health carrier that is the subject of the external review;(2) The covered person whose treatment is the subject of the external review or the covered person’s authorized representative;(3) Any officer, director or management employee of the health carrier that is the subject of the external review;(4) The healthcare provider, the healthcare provider’s medical group or independent practice association recommending the healthcare service or treatment that is the subject of the external review;(5) The facility at which the recommended healthcare service or treatment would be provided; or(6) The developer or manufacturer of the principal drug, device, procedure or other therapy being recommended for the covered person whose treatment is the subject of the external review.(e) In determining whether an external review organization or a clinical reviewer of the external review organization has a material professional, familial or financial conflict of interest for purposes of subsection (d), the commissioner shall take into consideration situations where the external review organization conducting an external review of a specified case or a clinical reviewer to be assigned by the external review organization to conduct an external review of a specified case may have an apparent professional, familial or financial relationship or connection with a person described in subsection (d), but that the characteristics of that relationship or connection are such that they are not a material professional, familial or financial conflict of interest that results in the disapproval of the independent review organization or the clinical reviewer from conducting the external review.(f) An external review organization that is accredited by a nationally recognized private accrediting entity that has external review accreditation standards that the commissioner has determined are equivalent to or exceed the minimum qualifications of this section shall be presumed in compliance with this section to be eligible for approval under § 56-61-122.(g) The commissioner shall initially review and periodically review the external review organization accreditation standards of a nationally recognized private accrediting entity to determine whether the entity’s standards are, and continue to be, equivalent to or exceed the minimum qualifications established under this section. The commissioner may accept a review conducted by NAIC for the purpose of the determination under this subsection (g).(h) Upon request, a nationally recognized private accrediting entity shall make its current external review organization accreditation standards available to the commissioner or NAIC in order for the commissioner to determine if the entity’s standards are equivalent to or exceed the minimum qualifications established under this section. The commissioner may exclude any private accrediting entity that is not reviewed by NAIC.(i) An external review organization shall be unbiased. An external review organization shall establish and maintain written procedures to ensure that it is and remains unbiased in addition to any other procedures required under this section.
