A Consumer Guide to Handling Disputes with Your Private or Employer Health Plan
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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.
| 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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