(a) For purposes of this section, “approved entity” means:

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Terms Used In Tennessee Code 56-61-112

  • Commissioner: means the commissioner of commerce and insurance. 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
  • written: includes printing, typewriting, engraving, lithography, and any other mode of representing words and letters. See Tennessee Code 1-3-105
(1) The utilization review accreditation commission (URAC); or
(2) Other nationally recognized private accrediting entity employing standards for the accreditation of external review programs that the commissioner deems are substantially equivalent to the standards for conducting an external review pursuant to §§ 56-61-113 – 56-61-118.
(b) A health carrier may elect, in writing to the commissioner, to conduct its external review program in accordance with:

(1) Sections 56-61-113 – 56-61-118, or
(2) The external review program of an approved entity; provided, that the health carrier receives and maintains accreditation from the approved entity. Sections 56-61-120 and 56-61-121 shall not apply to a health carrier that receives and maintains accreditation from the approved entity.
(c) The commissioner may evaluate the external review procedures of an approved entity. If after a hearing is conducted in accordance with the Uniform Administrative Procedures Act, compiled in title 4, chapter 5, the commissioner finds that an approved entity has amended its external review procedures to the extent that such procedures are no longer consistent with the purposes of this chapter, the commissioner shall issue a written order specifying in what respects those procedures are inconsistent.
(d) A health carrier that has elected to conduct its external review program in accordance with the standards of an approved entity, that is the subject of the commissioner’s order issued pursuant to subsection (c), shall have sixty (60) days from the effective date of the commissioner’s order to:

(1) Elect, in writing, to utilize another external review program under subsection (b); or
(2) Demonstrate to the commissioner’s satisfaction that the approved entity has subsequently amended its procedures so that such procedures are consistent with the purposes of this chapter.
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