(a) Within one hundred and eighty (180) days after the date of receipt of a notice of an adverse determination, an aggrieved person may file a grievance with the health carrier requesting a first level review of the adverse determination.
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Terms Used In Tennessee Code 56-61-107

  • 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
  • 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
  • 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
  • Department: means the department of commerce and insurance. See Tennessee Code 56-1-102
  • 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.
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • written: includes printing, typewriting, engraving, lithography, and any other mode of representing words and letters. See Tennessee Code 1-3-105
(b) The health carrier shall provide the aggrieved person with the name and address of the organizational unit or department designated to coordinate the first level review on behalf of the health carrier.
(c)

(1)

(A) An aggrieved person does not have the right to attend, or to have a representative in attendance at the first level review; provided, that the aggrieved person is entitled to:

(i) Submit written comments, documents, records and other material relating to the request for benefits for the reviewer or reviewers to consider when conducting the review; and
(ii) Receive from the health carrier, upon request and free of charge, reasonable access to, and copies of all documents, records and other information relevant to the covered person‘s request for benefits.
(B) For purposes of subdivision (c)(1)(A)(ii), a document, record or other information shall be considered relevant to an aggrieved person’s request for benefits if the document, record or other information:

(i) Was relied upon in making the benefit determination;
(ii) Was submitted, considered or generated in the course of making the adverse determination, without regard to whether the document, record or other information was relied upon in making the benefit determination;
(iii) Demonstrates that, in making the benefit determination, the health carrier or its designated representatives applied required administrative procedures and safeguards with respect to the covered person as other similarly situated covered persons; or
(iv) Constitutes a statement of policy or guidance with respect to the health benefit plan concerning the denied healthcare service or treatment for the covered person’s diagnosis, without regard to whether the advice or statement was relied upon in making the benefit determination.
(2) The health carrier shall make the provisions of subdivision (c)(1) known to the aggrieved person within five (5) business days after the date of receipt of the grievance; provided, that the request was made to the appropriate organizational unit or department designated by the health carrier.
(d) For purposes of calculating the time periods within which a determination is required to be rendered and notice provided under subsection (e), the time period shall begin on the date the grievance requesting the first level review is filed with the health carrier in accordance with the health carrier’s procedures established pursuant to this section, without regard to whether all of the information necessary to make the determination accompanies the filing.
(e)

(1) A health carrier shall notify and issue a decision, in writing or electronically, to the aggrieved person within the timeframes provided in subdivisions (e)(2) and (3).
(2) With respect to a grievance requesting a first level review of an adverse determination involving a prospective review request, the health carrier shall notify and issue a decision within a reasonable period of time that is appropriate given the covered person’s medical condition, but no later than thirty (30) days after the date of the health carrier’s receipt of the grievance requesting the first level review made pursuant to subsection (a).
(3) With respect to a grievance requesting a first level review of an adverse determination involving a retrospective review request, the health carrier shall notify and issue a decision within a reasonable period of time, but no later than sixty (60) days after the date of the health carrier’s receipt of the grievance requesting the first level review made pursuant to subsection (a).
(f) The decision issued pursuant to subsection (e) shall set forth, in a manner calculated to be understood by the aggrieved person:

(1) The titles and qualifying credentials of the person or persons participating and reviewing in the first level review;
(2) A statement of each reviewer’s understanding of the grievance;
(3) Each reviewer’s decision in clear terms and the contract basis or medical rationale in sufficient detail for the aggrieved person to respond further to the health carrier’s position;
(4) A reference to the evidence or documentation used as the basis for the decision;
(5) For a first level review decision issued pursuant to subsection (e) involving an adverse determination:

(A) The specific reason or reasons for the adverse determination;
(B) A reference to the specific plan provisions on which the determination is based;
(C) A statement that the aggrieved person is entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records and other information relevant, as the term “relevant” is defined in subdivision (c)(1)(B), to the covered person’s benefit request;
(D) If the health carrier relied upon an internal rule, guideline, protocol or other similar criterion to make the adverse determination, either the specific rule, guideline, protocol or other similar criterion or a statement that a specific rule, guideline, protocol or other similar criterion was relied upon to make the adverse determination and that a copy of the rule, guideline, protocol or other similar criterion will be provided free of charge to the aggrieved person upon request and the date such policy was effective;
(E) If the adverse determination is based on medical necessity, either an explanation of the criteria for making the determination, applying the terms of the health benefit plan to the covered person’s medical circumstances, or a statement that an explanation will be provided to the aggrieved person, free of charge upon request; and
(F) If applicable, instructions for requesting:

(i) A copy of the rule, guideline, protocol or other similar criterion relied upon in making the adverse determination, as provided in subdivision (f)(5)(D); and
(ii) The written statement of the criteria for the determination, as provided in subdivision (f)(5)(E);
(6) If applicable, a statement indicating:

(A) A description of the process to obtain a second level review of the first level review’s decision involving an adverse determination, if the aggrieved person wishes to request a second level review pursuant to § 56-61-108;
(B) The written procedures governing the second level review, including any required timeframe for the review; and
(C) A description of the procedures for obtaining an external review of the adverse determination pursuant to this chapter if the aggrieved person decides not to file for a second review of the first level review’s decision involving an adverse determination.
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