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Tennessee
General Information and Internal Plan Review:
For HMOs, Tennessee requires consumers to use their health plan’s
internal grievance process prior to asking the Commissioner of
the Insurance Division for a review. Health plans must provide
not only an initial review, but also a reconsideration of the
review if you request one.
If you are unsatisfied with the results of your review you may either
ask your health plan for an independent review, which can cost $50, or
can ask the Insurance Division to review the decision, which is available
at no charge. The two processes use different rules and timelines; independent
review through the health plan is described below. HMO grievances filed
with the Insurance Division are reviewed by Division staff, which includes
a physician.
The Independent Review Process:
Whom to contact: |
Your health plan |
Who can appeal: |
You or your authorized
representative |
What you can appeal: |
Denials of coverage
for services the health plan determines are
not medically necessary or are experimental.
The cost of the proposed service to the health
plan must be at least $500. |
When you can appeal: |
After completing
the HMO internal grievance process, within
60 days of receiving final notification that
coverage will be denied. |
What to send: |
A written letter
including any pertinent documentation |
What you must pay: |
Up to $50 |
What will happen: |
- Your health plan has 5 days to provide
all pertinent information to the independent
review entity.
- The independent review entity will request
any additional information from you and
your doctor within 5 days of receiving the
information from the health plan.
- The independent review entity will review
your case and make a decision.
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When you will get
a decision: |
Within 30 days
of receiving the request for review. (The expert
may request an extension of 5 additional days
to consider additional information.) |
In urgent situations: |
For life-threatening
conditions, a decision will be made within
5 days. |
How to Get More Information:
Tennessee Department of Commerce and Insurance, 615-741-2825
or 800-861-1270
Information updated as of 2-7-2005
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