(a) It is the intent of this section to establish a procedure to verify that the HMOs and behavioral health organizations participating by contract in the TennCare program are delivering the health benefits required under their TennCare contracts with the state. This procedure shall also assure that each of these entities have adequate provider networks to ensure the effective and efficient delivery of health care services to TennCare enrollees.
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Terms Used In Tennessee Code 56-32-131

  • Advice and consent: Under the Constitution, presidential nominations for executive and judicial posts take effect only when confirmed by the Senate, and international treaties become effective only when the Senate approves them by a two-thirds vote.
  • Commissioner: means the commissioner of commerce and insurance. See Tennessee Code 56-32-102
  • Contract: A legal written agreement that becomes binding when signed.
  • Department: means the department of commerce and insurance. See Tennessee Code 56-1-102
  • Health care services: means any services included in the furnishing to any individual of medical or dental care, or hospitalization, or incidental to the furnishing of the care or hospitalization, as well as the furnishing to any person of any and all other services for the purpose of preventing, alleviating, curing, or healing human illness, injury or physical disability. See Tennessee Code 56-32-102
  • Provider: means any physician, hospital or other person that is licensed or otherwise authorized in this state to furnish health care services. See Tennessee Code 56-32-102
  • 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
(b) The commissioner, with the advice and consent of the office of the comptroller of the treasury, shall contract with an entity independent of the state of Tennessee to conduct annual reviews of organizations contracting with the state in the TennCare program. The contract shall be entered into in accordance with appropriate state procedures. The purpose of this contract shall be to verify, on an annual basis, that each HMO and behavioral health organization contracting with the state of Tennessee in the TennCare program is delivering health care services in conformity with the TennCare contract and applicable statutory authority. This annual review shall include verifying that each of these organizations maintains an adequate network. The standards for network adequacy are defined by the TennCare contract and applicable statutes and regulations. Nothing in this subsection (b) precludes the expansion of the state’s current contract with its External Quality Review Organization (EQRO) to include having the EQRO conduct this review. The contractor shall submit all findings for each organization in writing to the commissioner, the comptroller of the treasury and the director of the TennCare bureau.
(c) The department of commerce and insurance is authorized to conduct a survey of persons disenrolled by the TennCare program to determine if the persons were able to procure health insurance in the private market, or otherwise had access to healthcare benefits. The survey will not commence until a survey form is developed with the assistance of the TennCare bureau of the department of finance and administration, adopted by the commissioner of commerce and insurance, and approved by the state comptroller of the treasury. The survey will be conducted of persons who were disenrolled during the period from January 1, 2002, to December 31, 2002.
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