(a) A health carrier shall notify the aggrieved person in writing of the right to request an external review to be conducted pursuant to §§ 56-61-116 and 56-61-118 and include the appropriate statements and information set forth in subsection (b) at the same time that the health carrier sends written notice of a final adverse determination. As part of the written notice required under this subsection (a), a health carrier shall include the following, or substantially equivalent language:

We have denied your request for the provision of or payment for a healthcare service or course of treatment. You have the right to have our decision reviewed by healthcare professionals who have no association with us if our decision involved making a judgment as to the medical necessity, appropriateness, healthcare setting, level of care or effectiveness of the healthcare service or treatment you requested by submitting a written request for external review to us.

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Terms Used In Tennessee Code 56-61-113

  • 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
  • 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
  • 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
  • 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
  • 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 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
  • provider: means a healthcare professional or a facility. See Tennessee Code 56-61-102
  • 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 include the following in the notice required under subsection (a):

(1) For a notice related to an adverse determination, a statement informing the aggrieved person that:

(A) If the covered person has a medical condition where the timeframe for completion of an expedited review of a grievance involving an adverse determination set forth in § 56-61-109 would seriously jeopardize the life or health of the covered person or would jeopardize the covered person’s ability to regain maximum function, the aggrieved person may file a request for an expedited external review to be conducted pursuant to § 56-61-117;
(B) The aggrieved person may file a grievance under the health carrier’s internal grievance process as set forth in § 56-61-107. An aggrieved person shall be considered to have exhausted the health carrier’s internal grievance process for purposes of this section, if the aggrieved person:

(i) Has filed a grievance involving an adverse determination pursuant to § 56-61-107; and
(ii) Has not received a written decision on the grievance from the health carrier within thirty (30) days for prospective review determinations and sixty (60) days for retrospective review determinations following the date the aggrieved person filed the grievance with the health carrier unless the aggrieved person requested or agreed to a delay;
(2) For a notice related to a final adverse determination, a statement informing the aggrieved person that:

(A) If the covered person has a medical condition where the timeframe for completion of a standard external review pursuant to § 56-61-116 or § 56-61-118 would seriously jeopardize the life or health of the covered person or would jeopardize the covered person’s ability to regain maximum function, the aggrieved person may file a request for an expedited external review pursuant to § 56-61-117 or § 56-61-118(n);
(B) If the final adverse determination concerns an admission, availability of care, continued stay or healthcare service for which the covered person received emergency services, but has not been discharged from a facility, the aggrieved person may file a request for an expedited external review pursuant to § 56-61-117 or § 56-61-118(n).
(c) In addition to the information to be provided pursuant to subdivision (b)(1), the health carrier shall include a copy of the description of both the standard and expedited external review procedures highlighting the provisions in the external review procedures that give the aggrieved person the opportunity to submit additional information and any forms used to process an external review.
(d) As part of any forms provided under subdivision (b)(2), the health carrier shall include an authorization form that complies with the requirements of 45 C.F.R. § 164.508, by which the covered person, for purposes of conducting an external review under this chapter, authorizes the health carrier and the covered person’s treating healthcare provider to disclose protected health information, including, but not limited to, medical records concerning the covered person that are pertinent to the external review.
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