2021 Tennessee Code
Chapter 61 - Tennessee Health Carrier Grievance and External Review Procedure Act
§ 56-61-109. Establishment of Written Procedures for Expedited Review of Urgent Care Requests of Grievances Involving Adverse Determination

Reference to the specific plan provisions on which the determination is based;
A description of any additional material or information necessary for the covered person to complete the request, including an explanation of why the material or information is necessary to complete the request;
If the health carrier relied upon an internal rule, guideline, protocol or other similar criterion, effective at the time of service, to make the adverse determination, either the specific rule, guideline, protocol or other similar criterion or a statement that a specific rule, guideline, protocol or other similar criterion was relied upon to make the adverse determination and a copy of the rule, guideline, protocol or other similar criterion will be provided free of charge to the aggrieved person upon request;
If the adverse determination is based on medical necessity, an explanation of the criteria for making the determination, applying the terms of the health benefit plan to the covered person's medical circumstances or a statement that an explanation will be provided to the aggrieved person free of charge upon request;
If applicable, instructions for requesting:
A copy of the rule, guideline, protocol or other similar criterion relied upon in making the adverse determination in accordance with subdivision (h)(1)(E)(iv); or
The written statement of the criteria for the adverse determination in accordance with subdivision (h)(1)(E)(v); and
A statement describing the procedures for obtaining an external review of the adverse determination pursuant to this chapter.
(A)  A health carrier may provide the notice required under this section orally, in writing or electronically.
If notice of the adverse determination is provided orally, the health carrier shall provide written or electronic notice of the adverse determination within three (3) days following such oral notification.

Structure 2021 Tennessee Code