§ 56-61-101 Short Title — Purpose
§ 56-61-102 Chapter Definitions
§ 56-61-103 Applicability and Scope
§ 56-61-104 No Limitations or Restrictions on Denying Coverage of Services Not Medically Necessary
§ 56-61-105 Maintenance of Register of Written Records to Document Grievances
§ 56-61-106 Written Procedures for Grievances
§ 56-61-107 First Level Review of Adverse Determination
§ 56-61-108 Second Level Review of Adverse Determination
§ 56-61-109 Establishment of Written Procedures for Expedited Review of Urgent Care Requests of Grievances Involving Adverse Determination
§ 56-61-110 Rules and Regulations
§ 56-61-111 Penalties for Violations
§ 56-61-112 Elections for Conducting External Review Program
§ 56-61-113 Notice of Right to External Review
§ 56-61-114 Request for External Review
§ 56-61-115 Exhaustion of Internal Grievance Process
§ 56-61-116 Standard External Review
§ 56-61-117 Expedited External Review
§ 56-61-118 Requests for External Review When Service or Treatment Determined to Be Investigational
§ 56-61-119 Binding Nature of External Review Decisions
§ 56-61-120 Approval of External Review Organizations
§ 56-61-121 Minimum Qualifications for Independent Review Organizations
§ 56-61-122 Hold Harmless for External Review Organizations
§ 56-61-123 External Review Reporting Requirements
§ 56-61-124 Funding of External Review
§ 56-61-125 Disclosure Requirements

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

  • Adult: means any person eighteen (18) years of age or older. See Tennessee Code 37-1-102
  • Adverse determination: means :
    1. 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
    2. Affidavit: A written statement of facts confirmed by the oath of the party making it, before a notary or officer having authority to administer oaths.
    3. Aggrieved person: means :
      1. A healthcare provider. See Tennessee Code 56-61-102
      2. Allegation: something that someone says happened.
      3. 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
      4. Authorized representative: means :
        1. 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
        2. 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
        3. Caregiver: means any relative or other person living, visiting, or working in the child's home who supervises or otherwise provides care or assistance for the child, such as a babysitter, or who is an employee or volunteer with the responsibility for any child at an educational, recreational, medical, religious, therapeutic, or other setting where children are present. See Tennessee Code 37-1-102
        4. Child: means :
          1. A person under eighteen (18) years of age. See Tennessee Code 37-1-102
          2. 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
          3. 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
          4. 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
          5. Commissioner: means commissioner of children's services. See Tennessee Code 37-1-102
          6. Commissioner: means the commissioner of commerce and insurance. See Tennessee Code 56-61-102
          7. Court order: means any order or decree of a judge, magistrate or court of competent jurisdiction. See Tennessee Code 37-1-102
          8. Covered person: means a policyholder, subscriber, enrollee or other individual participating in a health benefit plan. See Tennessee Code 56-61-102
          9. Custodian: means a person, other than a parent or legal guardian, who stands in loco parentis to the child or a person to whom temporary legal custody of the child has been given by order of a court. See Tennessee Code 37-1-102
          10. Custody: means the control of actual physical care of the child and includes the right and responsibility to provide for the physical, mental, moral and emotional well-being of the child. See Tennessee Code 37-1-102
          11. Department: means the department of commerce and insurance. See Tennessee Code 56-1-102
          12. Department: means the department of children's services. See Tennessee Code 37-1-102
          13. Detention: means temporary confinement in a secure or closed type of facility that is under the direction or supervision of the court or a facility that is designated by the court or other authority as a place of confinement for juveniles. See Tennessee Code 37-1-102
          14. 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
          15. Emergency services: means healthcare items and services furnished or required to evaluate and treat an emergency medical condition. See Tennessee Code 56-61-102
          16. Ex officio: Literally, by virtue of one's office.
          17. 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
          18. Extradition: The formal process of delivering an accused or convicted person from authorities in one state to authorities in another state.
          19. 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
          20. Felony: A crime carrying a penalty of more than a year in prison.
          21. 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
          22. Financial obligations: means fines, fees, costs, surcharges, child support, or other monetary liabilities ordered or assessed by any court or state or county government, but does not include restitution. See Tennessee Code 37-1-102
          23. Foster care: means the temporary placement of a child in the custody of the department of children's services or any agency or institution, whether public or private, for care outside the home of a parent or relative, by blood or marriage, of the child, whether the placement is by court order, voluntary placement agreement, surrender of parental rights or otherwise. See Tennessee Code 37-1-102
          24. Grievance: means a written appeal of an adverse determination or final adverse determination submitted by or on behalf of a covered person regarding:
            1. Availability, delivery or quality of healthcare services regarding an adverse determination. See Tennessee Code 56-61-102
            2. 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.
            3. 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
            4. 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
            5. 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
            6. 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
            7. Indictment: The formal charge issued by a grand jury stating that there is enough evidence that the defendant committed the crime to justify having a trial; it is used primarily for felonies.
            8. insurance company: includes all corporations, associations, partnerships, or individuals engaged as principals in the business of insurance. See Tennessee Code 56-1-102
            9. Juvenile court: means the general sessions court in all counties of this state, except in those counties and municipalities in which special juvenile courts are provided by law, and "judge" means judge of the juvenile court. See Tennessee Code 37-1-102
            10. Managed care plan: includes :
              1. A closed plan, as defined in subdivision (6). See Tennessee Code 56-61-102
              2. 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:
                1. In accordance with generally accepted standards of medical practice. See Tennessee Code 56-61-102
                2. Medical or scientific evidence: means evidence found in the following sources. See Tennessee Code 56-61-102
                3. Minor: means any person who has not attained eighteen (18) years of age. See Tennessee Code 1-3-105
                4. NAIC: means the National Association of Insurance Commissioners. See Tennessee Code 56-61-102
                5. Nonjudicial days: means Saturdays, Sundays and legal holidays. See Tennessee Code 37-1-102
                6. 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
                7. 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
                8. Plea: In a criminal case, the defendant's statement pleading "guilty" or "not guilty" in answer to the charges, a declaration made in open court.
                9. Positive behavior: means prosocial behavior or progress in a treatment program or on supervision. See Tennessee Code 37-1-102
                10. Probation: means casework service as directed by the court and pursuant to this part as a measure for the protection, guidance, and well-being of the child and child's family. See Tennessee Code 37-1-102
                11. Probation: A sentencing alternative to imprisonment in which the court releases convicted defendants under supervision as long as certain conditions are observed.
                12. Probation officers: Screen applicants for pretrial release and monitor convicted offenders released under court supervision.
                13. 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
                14. provider: means a healthcare professional or a facility. See Tennessee Code 56-61-102
                15. 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
                16. Remand: When an appellate court sends a case back to a lower court for further proceedings.
                17. Restitution: means compensation that is accomplished through actual monetary payment to the victim of the offense by the child who committed the offense, or symbolically, through unpaid community service work by the child, for property damage or loss incurred as a result of the delinquent offense. See Tennessee Code 37-1-102
                18. Retrospective review: means any review of a request for a benefit that is not a prospective review request. See Tennessee Code 56-61-102
                19. Shelter care: means temporary care of a child in physically unrestricted facilities. See Tennessee Code 37-1-102
                20. Subscriber: means a person obligated under a reciprocal insurance agreement. See Tennessee Code 56-16-102
                21. Unruly child: means a child in need of treatment and rehabilitation who:
                  1. Habitually and without justification is truant from school while subject to compulsory school attendance under § 49-6-3007. See Tennessee Code 37-1-102
                  2. Uphold: The decision of an appellate court not to reverse a lower court decision.
                  3. 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:
                    1. 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
                    2. Validated risk and needs assessment: means a determination of a child's risk to reoffend and the needs that, when addressed, reduce the child's risk to reoffend through the use of an actuarial assessment tool that assesses the dynamic and static factors that predict delinquent behavior. See Tennessee Code 37-1-102