Terms Used In Tennessee Code > Title 56 > Chapter 61 - Tennessee Health Carrier Grievance and External Review Procedure Act

• abandonment: means that:
  (i)

  (a) If the child is four (4) years of age or more, for a period of four (4) consecutive months immediately preceding the filing of a proceeding, pleading, petition, or amended or supplemental petition to terminate the parental rights of the parent or parents or the guardian or guardians of the child who is the subject of the petition for termination of parental rights or adoption, the parent or parents or the guardian or guardians either have failed to visit or have failed to support or have failed to make reasonable payments toward the support of the child. See Tennessee Code 36-1-102
• Adopted person: means :
  (A) Any person who is or has been adopted under this part or under the laws of any state, territory, or foreign country. See Tennessee Code 36-1-102
• Adoption: means the social and legal process of establishing by court order, other than by paternity or legitimation proceedings or by voluntary acknowledgment of paternity, the legal relationship of parent and child. See Tennessee Code 36-1-102
• Adoption assistance: means the federal or state programs that exist to provide financial assistance to adoptive parents to enable them to provide a permanent home to a special needs child as defined by the department. See Tennessee Code 36-1-102
• Adoption record: means :
  (A)

  (i) The records, reports, or other documents maintained in any medium by the judge or clerk of the court, or by any other person pursuant to this part who is authorized to witness the execution of surrenders or revocations of surrenders, which records, reports, or documents relate to an adoption petition, a surrender or parental consent, a revocation of a surrender or parental consent, or which reasonably relate to other information concerning the adoption of a person, and which information in such records, reports, or documents exists during the pendency of an adoption or a termination of parental rights proceeding, or which records, reports, or documents exist subsequent to the conclusion of those proceedings, even if no order of adoption or order of dismissal is entered, but which records, reports or documents exist prior to those records, reports, or documents becoming a part of a sealed record or a sealed adoption record pursuant to §. See Tennessee Code 36-1-102
• Adoptive parent or parents: means the person or persons who have been made the legal parents of a child by the entry of an order of adoption under this part or under of the laws of any state, territory or foreign country. See Tennessee Code 36-1-102
• Adult: means any person who is eighteen (18) years of age or older. See Tennessee Code 36-1-102
• 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
• Affidavit: A written statement of facts confirmed by the oath of the party making it, before a notary or officer having authority to administer oaths.
• Aggrieved person: means :
  (A) A healthcare provider. See Tennessee Code 56-61-102
• Allegation: something that someone says happened.
• Answer: The formal written statement by a defendant responding to a civil complaint and setting forth the grounds for defense.
• Appellate: About appeals; an appellate court has the power to review the judgement of another lower court or tribunal.
• Attachment: A procedure by which a person's property is seized to pay judgments levied by the court.
• Attorney: means the person designated and authorized by subscribers as the attorney-in-fact having authority to obligate them on reciprocal insurance contracts. See Tennessee Code 56-16-102
• 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
• Beneficiary: A person who is entitled to receive the benefits or proceeds of a will, trust, insurance policy, retirement plan, annuity, or other contract. ^{Source: OCC}
• benefits: means those healthcare services to which a covered person is entitled under the terms of a health benefit plan. See Tennessee Code 56-61-102
• Bequest: Property gifted by will.
• Biological parents: means the woman and man who physically or genetically conceived the child who is the subject of the adoption or termination proceedings or who conceived the child who has made a request for information pursuant to this part. See Tennessee Code 36-1-102
• Chambers: A judge's office.
• Chartered child-placing agency: means an agency that had received a charter from the state of Tennessee through legislative action or by incorporation for the operation of an entity or a program of any type that engaged in the placement of children for foster care or residential care as part of a plan or program for which those children were or could have been made available for adoptive placement and that may have, at sometime during its existence, become subject to any licensing requirements by the department or its predecessors. See Tennessee Code 36-1-102
• children: means any person or persons under eighteen (18) years of age. See Tennessee Code 36-1-102
• 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
• 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
• Closed plan: means a managed care plan that requires covered persons to use participating providers under the terms of the managed care plan or the plan will not provide covered benefits to the covered person. See Tennessee Code 56-61-102
• Commissioner: means the commissioner of commerce and insurance. See Tennessee Code 56-61-102
• Complaint: A written statement by the plaintiff stating the wrongs allegedly committed by the defendant.
• Consent: means :
  (A) The written authorization to relinquish a child for adoption, which is given by an agency such as the department or a public child care agency of another state or country or licensed child-placing agency of this or another state, which agency has the authority, by court order or by surrender or by operation of law or by any combination of these, to place a child for adoption and to give permission for the adoption of that child by other persons. See Tennessee Code 36-1-102
• Conservator: means a person or entity appointed by a court to provide partial or full supervision, protection, and assistance of the person or property, or both, of a disabled adult pursuant to title 34, chapter 1 or the equivalent law of another state. See Tennessee Code 36-1-102
• Continuance: Putting off of a hearing ot trial until a later time.
• Contract: A legal written agreement that becomes binding when signed.
• Conviction: A judgement of guilt against a criminal defendant.
• court: includes the juvenile court for purposes of the authority to accept the surrender or revocation of surrenders of a child and to issue any orders of reference, orders of guardianship, or other orders resulting from a surrender or revocation that it accepts and for purposes of authorizing the termination of parental rights pursuant to §. See Tennessee Code 36-1-102
• Court report: means the report to the adoption or surrender court in response to an order of reference that describes to the court the status of the child and the prospective adoptive parents or the persons to whom the child is surrendered. See Tennessee Code 36-1-102
• Covered person: means a policyholder, subscriber, enrollee or other individual participating in a health benefit plan. See Tennessee Code 56-61-102
• Damages: Money paid by defendants to successful plaintiffs in civil cases to compensate the plaintiffs for their injuries.
• Department: means the department of commerce and insurance. See Tennessee Code 56-1-102
• Department: means the department of children's services or any of its divisions or units. See Tennessee Code 36-1-102
• Dependent: A person dependent for support upon another.
• disability: means that the individual is a minor pursuant to any state, territorial, or federal law, or the law of any foreign country, or that the individual has been determined by any such laws to be in need of a person or entity to care for the individual due to that individual's physical or mental incapacity or infirmity. See Tennessee Code 36-1-102
• Discovery: Lawyers' examination, before trial, of facts and documents in possession of the opponents to help the lawyers prepare for trial.
• Dismissal: The dropping of a case by the judge without further consideration or hearing. ^Source:
• Docket: A log containing brief entries of court proceedings.
• Eligible person: means , for purposes of §. See Tennessee Code 36-1-102
• Emergency medical condition: means the sudden and, at the time, unexpected onset of a health condition that requires immediate medical attention, where failure to provide medical attention would result in serious impairment to bodily functions, serious dysfunction of a bodily organ or part, or would place the person's health in serious jeopardy. 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
• Equitable: Pertaining to civil suits in "equity" rather than in "law." In English legal history, the courts of "law" could order the payment of damages and could afford no other remedy. See damages. A separate court of "equity" could order someone to do something or to cease to do something. See, e.g., injunction. In American jurisprudence, the federal courts have both legal and equitable power, but the distinction is still an important one. For example, a trial by jury is normally available in "law" cases but not in "equity" cases. ^{Source: U.S. Courts}
• 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
• 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
• failed to visit: means the failure, for the applicable time period, to visit or engage in more than token visitation. See Tennessee Code 36-1-102
• 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
• Final court report: means a written document completed by the department or a licensed child-placing agency or licensed clinical social worker after submission of any prior court reports in response to the court's order of reference. See Tennessee Code 36-1-102
• Financially able: means that the petitioners for adoption of a child are able, by use of any and all income and economic resources of the petitioners, including, but not limited to, assistance from public or private sources, to ensure that any physical, emotional, or special needs of the child are met. See Tennessee Code 36-1-102
• Foster care: has the meaning given to that term in §. See Tennessee Code 36-1-102
• 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
• Guardian: A person legally empowered and charged with the duty of taking care of and managing the property of another person who because of age, intellect, or health, is incapable of managing his (her) own affairs.
• Guardian: means a person or entity appointed by a court to provide care, custody, control, supervision, and protection for a child, and authorized by the court to adopt or consent to the adoption of the child as a result of a surrender, parental consent, or termination of parental rights. See Tennessee Code 36-1-102
• Guardianship: means the status created by a court order appointing a person or entity guardian of the child. See Tennessee Code 36-1-102
• 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
• Home study: means the product of a preparation process in which individuals or families are assessed by themselves and the department or licensed child-placing agency, or a licensed clinical social worker as to their suitability for adoption and their desires with regard to the child they wish to adopt. See Tennessee Code 36-1-102
• Interrogatories: Written questions asked by one party of an opposing party, who must answer them in writing under oath; a discovery device in a lawsuit.
• Joint resolution: A legislative measure which requires the approval of both chambers.
• Legal parent: means :
  (i) The biological mother of a child. See Tennessee Code 36-1-102
• Legal relative: means a person who is included in the class of persons set forth in the definition of "biological relative" or "legal parent" and who, at the time a request for services or information is made pursuant to §. See Tennessee Code 36-1-102
• Legal representative: means :
  (i) The conservator, guardian, legal custodian, or other person or entity with legal authority to make decisions for an individual with a disability or an attorney-in-fact, an attorney at law representing a person for purposes of obtaining information pursuant to this part, or the legally appointed administrator, executor, or other legally appointed representative of a person's estate. See Tennessee Code 36-1-102
• Licensed child-placing agency: means any agency operating under a license to place children for adoption issued by the department, or operating under a license from any governmental authority from any other state or territory or the District of Columbia, or any agency that operates under the authority of another country with the right to make placement of children for adoption and that has, in the department's sole determination, been authorized to place children for adoption in this state. See Tennessee Code 36-1-102
• Licensed clinical social worker: means an individual who holds a license as an independent practitioner from the board of social worker certification and licensure pursuant to title 63, chapter 23, and, in addition, is licensed by the department to provide adoption placement services. See Tennessee Code 36-1-102
• Lineal ancestor: means any degree of grandparent or great-grandparent, either by birth or adoption. See Tennessee Code 36-1-102
• Litigation: A case, controversy, or lawsuit. Participants (plaintiffs and defendants) in lawsuits are called litigants.
• Managed care plan: includes :
  (A) A closed plan, as defined in subdivision (6). 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
• Medical or scientific evidence: means evidence found in the following sources. See Tennessee Code 56-61-102
• Minor: means any person who has not attained eighteen (18) years of age. See Tennessee Code 1-3-105
• NAIC: means the National Association of Insurance Commissioners. See Tennessee Code 56-61-102
• Oath: A promise to tell the truth.
• Oath: includes affirmation. See Tennessee Code 1-3-105
• Open plan: means a managed care plan, other than a closed plan, that provides incentives, including financial incentives, for covered persons to use participating providers under the terms of the managed care plan. See Tennessee Code 56-61-102
• Order of reference: means the order from the court where the surrender is executed or filed or where the adoption petition is filed that directs the department or a licensed child-placing agency or licensed clinical social worker to conduct a home study or preliminary home study or to complete a report of the status of the child who is or may be the subject of an adoption proceeding, and that seeks information as to the suitability of the prospective adoptive parents to adopt a child. See Tennessee Code 36-1-102
• Parental consent: means the consent described in subdivision (16)(C). See Tennessee Code 36-1-102
• Parental rights: means the legally recognized rights and responsibilities to act as a parent, to care for, to name, and to claim custodial rights with respect to a child. See Tennessee Code 36-1-102
• parents: means any biological, legal, adoptive parent or parents or, for purposes of §. See Tennessee Code 36-1-102
• Partnership: A voluntary contract between two or more persons to pool some or all of their assets into a business, with the agreement that there will be a proportional sharing of profits and losses.
• 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
• Physical custody: means physical possession and care of a child. See Tennessee Code 36-1-102
• Pleadings: Written statements of the parties in a civil case of their positions. In the federal courts, the principal pleadings are the complaint and the answer.
• Post-adoption record: means :
  (A) The record maintained in any medium by the department, separately from the sealed record or sealed adoption record and subsequent to the sealing of an adoption record or that is maintained about any sealed record or sealed adoption record. See Tennessee Code 36-1-102
• Preliminary hearing: A hearing where the judge decides whether there is enough evidence to make the defendant have a trial.
• Preliminary home study: means an initial home study conducted prior to or, in limited situations, immediately after, the placement of a child with prospective adoptive parents who have not previously been subject to a home study that was conducted or updated not less than six (6) months prior to the date a surrender is sought to be executed to the prospective adoptive parents or prior to the date of the filing of the adoption petition. See Tennessee Code 36-1-102
• Probable cause: A reasonable ground for belief that the offender violated a specific law.
• Prospective adoptive parents: means a nonagency person or persons who are seeking to adopt a child and who have made application with a licensed child-placing agency or licensed clinical social worker or the department for approval, or who have been previously approved, to receive a child for adoption, or who have received or who expect to receive a surrender of a child, or who have filed a petition for termination or for adoption. See Tennessee Code 36-1-102
• 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
• Putative father: means a biological or alleged biological father of a child who, at the time of the filing of the petition to terminate the parental rights of such person, or if no such petition is filed, at the time of the filing of a petition to adopt a child, meets at least one (1) of the criteria set out in §. See Tennessee Code 36-1-102
• Register: means the written records kept by a health carrier to document all grievances received during a calendar year. See Tennessee Code 56-61-102
• Related: means grandparents or any degree of great-grandparents, aunts or uncles, or any degree of great-aunts or great-uncles, or stepparent, or cousins of the first degree, or first cousins once removed, or any siblings of the whole or half degree or any spouse of the above listed relatives. See Tennessee Code 36-1-102
• Remainder: An interest in property that takes effect in the future at a specified time or after the occurrence of some event, such as the death of a life tenant.
• Representative: when applied to those who represent a decedent, includes executors and administrators, unless the context implies heirs and distributees. See Tennessee Code 1-3-105
• Rescission: The cancellation of budget authority previously provided by Congress. The Impoundment Control Act of 1974 specifies that the President may propose to Congress that funds be rescinded. If both Houses have not approved a rescission proposal (by passing legislation) within 45 days of continuous session, any funds being withheld must be made available for obligation.
• Retrospective review: means any review of a request for a benefit that is not a prospective review request. See Tennessee Code 56-61-102
• Sealed adoption record: means :
  (i) The adoption record as it exists subsequent to its transmittal to the department, or subsequent to its sealing by the court, pursuant to the requirements of §. See Tennessee Code 36-1-102
• Sealed record: means :
  (i) Any records, reports, or documents that are maintained at any time by a court, a court clerk, a licensed or chartered child-placing agency, licensed clinical social worker, the department, the department of health, or any other information source concerning the foster care or agency care placement, or placement for adoption, of a person by any branch of the Tennessee children's home society authorized by chapter 113 of the Public Acts of 1919. See Tennessee Code 36-1-102
• Service of process: The service of writs or summonses to the appropriate party.
• sex: means a person's immutable biological sex as determined by anatomy and genetics existing at the time of birth and evidence of a person's biological sex. See Tennessee Code 1-3-105
• Sibling: means anyone having a sibling relationship. See Tennessee Code 36-1-102
• signed: includes a mark, the name being written near the mark and witnessed, or any other symbol or methodology executed or adopted by a party with intention to authenticate a writing or record, regardless of being witnessed. See Tennessee Code 1-3-105
• Subscriber: means a person obligated under a reciprocal insurance agreement. See Tennessee Code 56-16-102
• Surrender: means a document executed under §. See Tennessee Code 36-1-102
• Testator: A male person who leaves a will at death.
• Testimony: Evidence presented orally by witnesses during trials or before grand juries.
• token visitation: means that the visitation, under the circumstances of the individual case, constitutes nothing more than perfunctory visitation or visitation of such an infrequent nature or of such short duration as to merely establish minimal or insubstantial contact with the child. See Tennessee Code 36-1-102
• Trial: A hearing that takes place when the defendant pleads "not guilty" and witnesses are required to come to court to give evidence.
• Uphold: The decision of an appellate court not to reverse a lower court decision.
• 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