(a) Each health carrier shall include a description of the external review procedures in or attached to the membership booklet, provider manual, and health carrier’s web site. The health carrier may include a description of the external review procedures in the policy, certificate, outline of coverage, or other evidence of coverage provided to covered persons and providers.

Terms Used In Tennessee Code 56-61-125

  • 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
  • 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.
  • 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
  • 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
  • provider: means a healthcare professional or a facility. See Tennessee Code 56-61-102
(b) The disclosure required by subsection (a) shall be in a format prescribed by the commissioner.
(c) The description required under subsection (a) shall include a statement that informs the aggrieved person of the aggrieved person‘s right to file a request for an external review of an adverse determination or final adverse determination with the carrier. The statement shall include the telephone number and address of the commissioner.
(d) In addition to subsection (b), the statement shall inform the covered person that, when filing a request for an external review, the covered person will be required to authorize the release of any medical records of the covered person that may be required to be reviewed for the purpose of reaching a decision on the external review.
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