Terms Used In Tennessee Code > Title 56 > Chapter 61 - Tennessee Health Carrier Grievance and External Review Procedure Act

• 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
• Age of majority: means eighteen (18) years of age or older. See Tennessee Code 1-3-105
• Aggrieved person: means :
  (A) A healthcare provider. See Tennessee Code 56-61-102
• Amendment: A proposal to alter the text of a pending bill or other measure by striking out some of it, by inserting new language, or both. Before an amendment becomes part of the measure, thelegislature must agree to it.
• Answer: The formal written statement by a defendant responding to a civil complaint and setting forth the grounds for defense.
• Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
• Appellate: About appeals; an appellate court has the power to review the judgement of another lower court or tribunal.
• 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
• Child born out of wedlock: means a child born to parents who are not married to each other when the child was born. See Tennessee Code 36-2-302
• Clinical peer: means a physician or other healthcare professional who holds a nonrestricted license in a state of the United States and in the same or similar specialty that would typically manage the medical condition, procedure or treatment under review. 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
• Closed plan: means a managed care plan that requires covered persons to use participating providers under the terms of the managed care plan or the plan will not provide covered benefits to the covered person. See Tennessee Code 56-61-102
• Commissioner: means the commissioner of commerce and insurance. See Tennessee Code 56-61-102
• Complaint: A written statement by the plaintiff stating the wrongs allegedly committed by the defendant.
• Continuance: Putting off of a hearing ot trial until a later time.
• Contract: A legal written agreement that becomes binding when signed.
• Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
• Court: means the juvenile court or any trial court with general jurisdiction. See Tennessee Code 36-2-302
• Covered person: means a policyholder, subscriber, enrollee or other individual participating in a health benefit plan. See Tennessee Code 56-61-102
• Damages: Money paid by defendants to successful plaintiffs in civil cases to compensate the plaintiffs for their injuries.
• Defendant: In a civil suit, the person complained against; in a criminal case, the person accused of the crime.
• Department: means the department of commerce and insurance. See Tennessee Code 56-1-102
• Dismissal: The dropping of a case by the judge without further consideration or hearing. ^Source:
• Docket: A log containing brief entries of court proceedings.
• Emergency medical condition: means the sudden and, at the time, unexpected onset of a health condition that requires immediate medical attention, where failure to provide medical attention would result in serious impairment to bodily functions, serious dysfunction of a bodily organ or part, or would place the person's health in serious jeopardy. 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
• Equitable: Pertaining to civil suits in "equity" rather than in "law." In English legal history, the courts of "law" could order the payment of damages and could afford no other remedy. See damages. A separate court of "equity" could order someone to do something or to cease to do something. See, e.g., injunction. In American jurisprudence, the federal courts have both legal and equitable power, but the distinction is still an important one. For example, a trial by jury is normally available in "law" cases but not in "equity" cases. ^{Source: U.S. Courts}
• 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
• Father: means the biological father of a child born out of wedlock. See Tennessee Code 36-2-302
• 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
• Guardian: A person legally empowered and charged with the duty of taking care of and managing the property of another person who because of age, intellect, or health, is incapable of managing his (her) own affairs.
• 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
• insurance company: includes all corporations, associations, partnerships, or individuals engaged as principals in the business of insurance. See Tennessee Code 56-1-102
• Jurisdiction: (1) The legal authority of a court to hear and decide a case. Concurrent jurisdiction exists when two courts have simultaneous responsibility for the same case. (2) The geographic area over which the court has authority to decide cases.
• Litigation: A case, controversy, or lawsuit. Participants (plaintiffs and defendants) in lawsuits are called litigants.
• Managed care plan: includes :
  (A) A closed plan, as defined in subdivision (6). See Tennessee Code 56-61-102
• medical necessity: means healthcare services that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are:
  (A) In accordance with generally accepted standards of medical practice. See Tennessee Code 56-61-102
• Medical or scientific evidence: means evidence found in the following sources. See Tennessee Code 56-61-102
• Minor: means any person who has not attained eighteen (18) years of age. See Tennessee Code 1-3-105
• Mother: means the biological mother of a child born out of wedlock. See Tennessee Code 36-2-302
• NAIC: means the National Association of Insurance Commissioners. See Tennessee Code 56-61-102
• Obligation: An order placed, contract awarded, service received, or similar transaction during a given period that will require payments during the same or a future period.
• Open plan: means a managed care plan, other than a closed plan, that provides incentives, including financial incentives, for covered persons to use participating providers under the terms of the managed care plan. See Tennessee Code 56-61-102
• Parent: means the biological mother or biological father of a child, regardless of the marital status of the mother and father. See Tennessee Code 36-2-302
• Partnership: A voluntary contract between two or more persons to pool some or all of their assets into a business, with the agreement that there will be a proportional sharing of profits and losses.
• 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
• Person: includes a corporation, firm, company or association. See Tennessee Code 1-3-105
• Personal 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
• Prosecute: To charge someone with a crime. A prosecutor tries a criminal case on behalf of the government.
• Prospective review: means utilization review conducted prior to an admission or the provision of a healthcare service or a course of treatment in accordance with a health carrier's requirement that the healthcare service or course of treatment, in whole or in part, be approved prior to its provision or admission. See Tennessee Code 56-61-102
• provider: means a healthcare professional or a facility. See Tennessee Code 56-61-102
• Record: means information that is inscribed on a tangible medium or that is stored in an electronic or other medium and is retrievable in a perceivable form. See Tennessee Code 1-3-105
• Register: means the written records kept by a health carrier to document all grievances received during a calendar year. 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
• Retrospective review: means any review of a request for a benefit that is not a prospective review request. See Tennessee Code 56-61-102
• Service of process: The service of writs or summonses to the appropriate party.
• 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
• Statute: A law passed by a legislature.
• Subscriber: means a person obligated under a reciprocal insurance agreement. See Tennessee Code 56-16-102
• Summons: Another word for subpoena used by the criminal justice system.
• Testimony: Evidence presented orally by witnesses during trials or before grand juries.
• Trial: A hearing that takes place when the defendant pleads "not guilty" and witnesses are required to come to court to give evidence.
• 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.
• Urgent care request: means a request for a healthcare service or course of treatment with respect to which the time periods for making nonurgent care request determination:
  (i) Could seriously jeopardize the life or health of the covered person or the ability of the covered person to regain maximum function. See Tennessee Code 56-61-102
• written: includes printing, typewriting, engraving, lithography, and any other mode of representing words and letters. See Tennessee Code 1-3-105
• Year: means a calendar year, unless otherwise expressed. See Tennessee Code 1-3-105