Tennessee Code 56-61-116 – Standard external review
Current as of: 2024 | Check for updates
|
Other versions
Terms Used In Tennessee Code 56-61-116
- 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 - Clinical review criteria: means the written screening procedures, decision abstracts, clinical protocols and practice guidelines used by the health carrier to determine the medical necessity and appropriateness of healthcare services. See Tennessee Code 56-61-102
- Commissioner: means the commissioner of commerce and insurance. 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.
- External review organization: means an entity that conducts independent external reviews of adverse determinations and final adverse determinations of a health carrier. 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 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
- Healthcare professional: means a physician or other healthcare practitioner licensed, accredited or certified to perform specified healthcare services consistent with state law. See Tennessee Code 56-61-102
- Healthcare services: means services for the diagnosis, prevention, treatment, cure or relief of a health condition, illness, injury or disease. See Tennessee Code 56-61-102
- Medical or scientific evidence: means evidence found in the following sources. 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
- Retrospective review: means any review of a request for a benefit that is not a prospective review request. See Tennessee Code 56-61-102
- United States: includes the District of Columbia and the several territories of the United States. See Tennessee Code 1-3-105
- Uphold: The decision of an appellate court not to reverse a lower court decision.
- written: includes printing, typewriting, engraving, lithography, and any other mode of representing words and letters. See Tennessee Code 1-3-105