(a) Except as provided in subsection (b), a request for an external review pursuant to § 56-61-116 or § 56-61-118 shall not be made until the aggrieved person has exhausted the health carrier‘s internal grievance process as set forth in this chapter.

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Terms Used In Tennessee Code 56-61-115

  • 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
  • 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
  • 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
  • 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
(1) 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:

(A) Has filed a grievance involving an adverse determination pursuant to § 56-61-107; and
(B) 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 that the aggrieved person filed the grievance with the health carrier unless the aggrieved person requested or agreed to a delay.
(2) Notwithstanding subdivision (a)(1)(B), an aggrieved person may not file a request for an external review of an adverse determination involving a retrospective review determination until the covered person has exhausted the health carrier’s internal grievance process.
(b) A request for an external review of an adverse determination may be filed before the covered person has exhausted the health carrier’s internal grievance procedures, as set forth in § 56-61-107, whenever the health carrier agrees to waive the exhaustion requirement.
(c) If the requirement to exhaust the health carrier’s internal grievance procedures is waived pursuant to subsection (b), the aggrieved person may file a request in writing for a standard external review as set forth in § 56-61-116 or § 56-61-118.
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