(a) A health carrier shall establish written procedures for the expedited review of urgent care requests of grievances involving an adverse determination.
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Terms Used In Tennessee Code 56-61-109

  • 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
  • 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
  • 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
  • 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
  • Emergency services: means healthcare items and services furnished or required to evaluate and treat an emergency medical condition. 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.
  • 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
  • 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
  • provider: means a healthcare professional or a facility. See Tennessee Code 56-61-102
  • 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
(b) In addition to subsection (a), a health carrier shall provide expedited review of a grievance involving an adverse determination with respect to concurrent review of urgent care requests involving an admission, availability of care, continued stay or healthcare service for a covered person who has received emergency services, but has not been discharged from a facility.
(c) The procedures shall allow an aggrieved person to request an expedited review under this section orally, in writing or electronically.
(d) A health carrier shall appoint an appropriate clinical peer, or peers as would typically manage the case being reviewed, to review the adverse determination. The clinical peer or peers shall not have been involved in rendering the initial adverse determination.
(e) In an expedited review, the health carrier shall provide or transmit all necessary documents and information considered when making the adverse determination to the aggrieved person participating in the expedited review process electronically or by telephone, facsimile or any other expeditious method available.
(f)

(1) An expedited review decision shall be rendered and the aggrieved person shall be notified of the decision in accordance with subsection (h) as expeditiously as the covered person’s medical condition requires, but in no event more than seventy-two (72) hours after the receipt of the request for the expedited review.
(2) If the expedited review is of a grievance involving an adverse determination with respect to a concurrent review of an urgent care request, the service shall be continued until the covered person or covered person’s authorized representative has been notified of the determination or until the healthcare provider determines that the urgent care is no longer appropriate or necessary.
(g) For purposes of calculating the time periods within which a decision is required to be rendered under subsection (f), the time period within which the decision is required to be rendered shall begin on the date that the request is filed with the health carrier in accordance with the health carrier’s procedures established pursuant to § 56-61-107; without regard to whether all the information necessary to make the determination accompanies the filing.
(h)

(1) A notification of a decision under this section shall, in a manner calculated to be understood by the aggrieved person, set forth:

(A) The titles and qualifying credentials of the person or persons participating in the expedited review process;
(B) A statement of the reviewers’ understanding of the grievance;
(C) The reviewers’ 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;
(D) A reference to the evidence or documentation used as the basis for the decision; and
(E) If the decision involves an adverse determination, the notice shall provide:

(i) The specific reason or reasons for the adverse determination;
(ii) Reference to the specific plan provisions on which the determination is based;
(iii) A description of any additional material or information necessary for the covered person to complete the request, including an explanation of why the material or information is necessary to complete the request;
(iv) If the health carrier relied upon an internal rule, guideline, protocol or other similar criterion, effective at the time of service, 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 a copy of the rule, guideline, protocol or other similar criterion will be provided free of charge to the aggrieved person upon request;
(v) If the adverse determination is based on medical necessity, 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;
(vi) If applicable, instructions for requesting:

(a) A copy of the rule, guideline, protocol or other similar criterion relied upon in making the adverse determination in accordance with subdivision (h)(1)(E)(iv); or
(b) The written statement of the criteria for the adverse determination in accordance with subdivision (h)(1)(E)(v); and
(vii) A statement describing the procedures for obtaining an external review of the adverse determination pursuant to this chapter.
(2)

(A) A health carrier may provide the notice required under this section orally, in writing or electronically.
(B) If notice of the adverse determination is provided orally, the health carrier shall provide written or electronic notice of the adverse determination within three (3) days following such oral notification.
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