Tenn. Code Ann. § 56-1-308 — TN Code / Title 56 / Chapter 1 / Section 56-1-308
Penalty for violation of statute, rule or order - Recovery
Status: in_force

(a) With respect to any person required to be licensed, permitted, or authorized by any board, commission or agency attached to the division of regulatory boards, each respective board, commission or agency may assess a civil penalty against the person in an amount not to exceed one thousand dollars ($1,000) for each separate violation of a statute, rule or order pertaining to the board, commission or agency. Each day of continued violation constitutes a separate violation. (b) Each board, commission or agency shall by rule establish a schedule designating the minimum and maximum civil penalties that may be assessed under this section. In assessing civil penalties, the following factors may be considered: (1) Whether the amount imposed will be a substantial economic deterrent to the violator; (2) The circumstances leading to the violation; (3) The severity of the violation and the risk of harm to the public; (4) The economic benefits gained by the violator as a result of noncompliance; and (5) The interest of the public. (c) (1) Civil penalties assessed pursuant to this section shall become final thirty (30) days after the date a final order of assessment is served. Payment of any civil penalty assessed after a hearing held pursuant to the Uniform Administrative Procedures Act, compiled in title 4, chapter 5, is a prerequisite to issuance or renewal of any license issued by a board, commission or agency attached to the division unless the final decision of the board, commission or agency is stayed pursuant to § 4-5-322(c) , or acceptable arrangements for payment of the civil penalty are made with the board, commission or agency prior to the issuance or renewal of any license issued by a board, commission or agency attached to the division. (2) If the violator fails to pay an assessment when it becomes final, the division may apply to the appropriate court for a judgment and seek execution of the judgment. (3) Jurisdiction for recovery of the penalties shall be in the chancery court of Davidson County, or the chancery court of the county in which all or part of the violations occurred. (d) All sums recovered pursuant to this section shall be paid into the state treasury. Amended by 2013 Tenn. Acts, ch. 138,s 2, eff. 4/12/2013. Acts 1984, ch. 785, § 1; 1989, ch. 389, § 1.
(a) With respect to any person required to be licensed, permitted, or authorized by any board, commission or agency attached to the division of regulatory boards, each respective board, commission or agency may assess a civil penalty against the person in an amount not to exceed one thousand dollars ($1,000) for each separate violation of a statute, rule or order pertaining to the board, commission or agency. Each day of continued violation constitutes a separate violation.
(b) Each board, commission or agency shall by rule establish a schedule designating the minimum and maximum civil penalties that may be assessed under this section. In assessing civil penalties, the following factors may be considered: (1) Whether the amount imposed will be a substantial economic deterrent to the violator; (2) The circumstances leading to the violation; (3) The severity of the violation and the risk of harm to the public; (4) The economic benefits gained by the violator as a result of noncompliance; and (5) The interest of the public.
(1) Whether the amount imposed will be a substantial economic deterrent to the violator;
(2) The circumstances leading to the violation;
(3) The severity of the violation and the risk of harm to the public;
(4) The economic benefits gained by the violator as a result of noncompliance; and
(5) The interest of the public.
(c) (1) Civil penalties assessed pursuant to this section shall become final thirty (30) days after the date a final order of assessment is served. Payment of any civil penalty assessed after a hearing held pursuant to the Uniform Administrative Procedures Act, compiled in title 4, chapter 5, is a prerequisite to issuance or renewal of any license issued by a board, commission or agency attached to the division unless the final decision of the board, commission or agency is stayed pursuant to § 4-5-322(c) , or acceptable arrangements for payment of the civil penalty are made with the board, commission or agency prior to the issuance or renewal of any license issued by a board, commission or agency attached to the division. (2) If the violator fails to pay an assessment when it becomes final, the division may apply to the appropriate court for a judgment and seek execution of the judgment. (3) Jurisdiction for recovery of the penalties shall be in the chancery court of Davidson County, or the chancery court of the county in which all or part of the violations occurred.
(1) Civil penalties assessed pursuant to this section shall become final thirty (30) days after the date a final order of assessment is served. Payment of any civil penalty assessed after a hearing held pursuant to the Uniform Administrative Procedures Act, compiled in title 4, chapter 5, is a prerequisite to issuance or renewal of any license issued by a board, commission or agency attached to the division unless the final decision of the board, commission or agency is stayed pursuant to § 4-5-322(c) , or acceptable arrangements for payment of the civil penalty are made with the board, commission or agency prior to the issuance or renewal of any license issued by a board, commission or agency attached to the division.
(2) If the violator fails to pay an assessment when it becomes final, the division may apply to the appropriate court for a judgment and seek execution of the judgment.
(3) Jurisdiction for recovery of the penalties shall be in the chancery court of Davidson County, or the chancery court of the county in which all or part of the violations occurred.
(d) All sums recovered pursuant to this section shall be paid into the state treasury.
Amended by 2013 Tenn. Acts, ch. 138,s 2, eff. 4/12/2013.
Acts 1984, ch. 785, § 1; 1989, ch. 389, § 1.
Tenn. Code Ann. § 56-41-112 — TN Code / Title 56 / Chapter 41 / Section 56-41-112
Duration and effect of obligations and duties
Status: in_force

All obligations and duties arising under the plan of operation and under policies issued by the association shall remain in full force and effect during their terms. Acts 1987, ch. 439, § 11.
All obligations and duties arising under the plan of operation and under policies issued by the association shall remain in full force and effect during their terms.
Acts 1987, ch. 439, § 11.
Tenn. Code Ann. § 56-7-2601 — TN Code / Title 56 / Chapter 7 / Section 56-7-2601
Health insurance - Coverage of mental illness
Status: in_force

(a) As used in this section: (1) "Annual limit" means a dollar limitation on the total amount that may be paid for benefits in a twelve-month period under a health plan with respect to an individual or other coverage unit; (2) "Clinical staff" means an individual on the community mental health center staff who performs as a part of the treatment team diagnostic and/or counseling services and who holds at least a master's degree in either of the disciplines of psychology, nursing, or social work and any required license; and (3) "Community mental health center" means a private entity qualified as a tax exempt organization under § 501(c)(3) of the Internal Revenue Code ( 26 U.S.C. § 501(c)(3) ), or a public entity created by private act of the general assembly that: (A) Is primarily engaged in providing services for the diagnosis and treatment of emotionally disturbed and mentally ill persons, has a requirement that all mental health care be under a treatment plan approved and reviewed by a licensed physician or a licensed psychologist designated as a health care service provider, and has appropriate arrangements to assure that patients requiring medical services can be referred to a physician or hospital; and (B) Has been licensed as a mental health clinic facility by the department of mental health and substance abuse services, or by the licensing board of the state in which the community mental health center is located. (b) All other laws of this state notwithstanding, any individual, franchise, blanket or group policy of insurance issued pursuant to this title that provides hospital expense and surgical expense insurance and that is entered into, delivered, issued for delivery, or renewed, excepting individual insurance policy renewal, by agreement or otherwise, commencing on July 1, 1974, shall provide benefits for expense of residents of this state covered under the policy or plan, arising from psychiatric disorders, mental or nervous conditions, as described and defined in the Diagnostic Standard Manual of the American Psychiatric Association, alcoholism, drug dependence, both defined as mental illness in § 33-1-101 , or the medical complication of mental illness or intellectual disability, unless the policy or plan of insurance, excluding a TennCare health benefit plan, specifically excludes or reduces these benefits. This subsection (b) shall not apply to group policies or plans to which § 56-7-2360 applies. The medical and hospital benefits and coverage provided for the disorders, conditions and complications, if any, shall not be denied because of confinement in a particular facility; provided, that the facility is either: (1) A hospital licensed under title 33, chapter 2 or title 68, chapter 11, part 2, and accredited by the joint commission on the accreditation of hospitals; or (2) A hospital owned or operated by the state that is especially intended for use in the diagnosis, care and treatment of psychiatric, mental or nervous disorders, nor shall the benefits and coverage be denied on the basis that physician's services were performed by physicians not on the staff of a particular facility, so long as those services were rendered while insureds were hospitalized in that facility. (c) (1) After July 1, 1980, every insurer that proposes to issue a group hospital policy or a group major medical policy in this state and every nonprofit hospital and medical service plan corporation that proposes to issue group hospital, medical or major medical service plan contracts that provide coverage for the insured or the subscriber shall, in the case of outpatient expenses at a community mental health center, make available benefits as specified in this section for the care and treatment of mental, emotional or nervous disorders, alcoholism, drug dependence or the medical complication of mental illness or intellectual disability. (2) The benefits required to be made available by this subsection (c) shall be a part of each group policy or group contract described in this section, unless the policyholder or group contract subscriber rejects in writing the coverage. (3) (A) When benefits as specified in this section are made available for treatment received at the community mental health center, the benefits that cover services rendered by a physician in accordance with the policy or service plan contract shall also be made available when services are rendered by a member of the clinical staff, so long as the community mental health center has in effect a plan for quality assurance approved by the department of mental health and substance abuse services and the treatment is supervised by a licensed physician or a licensed psychologist designated as a health service provider. However, nothing in this subsection (c) may be construed to affect the license of a physician or psychologist designated as a health service provider providing the service or supervision. The benefits shall be provided at the usual and customary rates established by the community mental health center for the services rendered. However, the benefits provided shall be subject to deductibles and coinsurance factors that are not less favorable than for physical illness generally, and in no event shall coverage be required to be made available for more than thirty (30) outpatient visits per year. (B) With respect to benefits provided under subdivision (c)(3)(A) by a TennCare health benefit plan, the benefits provided are subject to deductibles and coinsurance factors that are not less favorable than for physical illness or the treatment of alcoholism or substance abuse generally, and coverage and reimbursement are not required to be made available for more than the number of visits per year offered for the treatment of alcoholism or substance abuse. (d) With respect to policies and contracts as described in subsection (c) that are delivered or issued for delivery in this state on or before July 1, 1980, each insurer and nonprofit hospital and medical service plan corporation shall notify the group policyholder or group contract holder of the availability of coverage described in subsection (c). The notification shall describe the benefits available and shall provide a means by which the policyholder or group contract holder may communicate acceptance or rejection of the coverage. (e) All group hospital and major medical policies delivered or issued for delivery in this state after July 1, 1980, and all group hospital, medical and major medical service plans commencing in this state after July 1, 1980, that provide benefits for expenses of residents of the state arising from psychiatric disorders, mental or nervous conditions, alcoholism, drug dependence or medical complication of mental illness or intellectual disability, shall reimburse for these benefits, if any, when the benefits are provided at a facility that is: (1) With respect to outpatient benefit, a community mental health center; (2) With respect to inpatient benefits, a community mental health center that has facilities for inpatient care and that has received a certificate of need from the Tennessee health facilities commission certifying the necessity of the facility if required by law; or (3) For persons covered under a TennCare health benefit plan, a residential or other mental health treatment facility licensed under title 33, chapter 2, part 4. (f) All individual, franchise, blanket, or group policies of insurance issued pursuant to this title that provide hospital expense and medical or surgical expense insurance and that are entered into, delivered, issued for delivery, or renewed, except individual insurance policy renewal, by agreement or otherwise, commencing on July 1, 1981, and that provide benefits for expenses of residents of the state arising from alcoholism, drug dependence or medical complication resulting from alcoholism, or drug dependence shall reimburse for these benefits, if any, when the benefits are provided at a facility that is a residential treatment facility licensed under title 33, chapter 2, part 4, and accredited by the joint commission on the accreditation of hospitals. (g) Subject to § 56-7-2360 , in general, with respect to group health plans issued by entities regulated pursuant to insurance law, for plan years beginning on or after January 1, 1998, certain mental health benefits are required as follows: (1) As to either aggregate lifetime limits or annual limits or both, for a group health plan providing both medical and surgical benefits and mental health benefits: (A) If the plan does not have a limit on substantially all medical and surgical benefits, the plan may not impose such a limit on mental health benefits; (B) If the plan has a limit on substantially all medical and surgical benefits, the plan shall either include mental health benefits under the limit applied to medical and surgical benefits or apply a separate limit to mental health benefits that is no less than the one applied to medical and surgical benefits; and (C) If the plan has varying limits on different medical or surgical benefits, the plan shall apply an average limit to mental health benefits with the average to be computed based on the weighted average of the varying limits; (2) No group health plan is required under this subsection (g) to provide mental health benefits; (3) This subsection (g) shall not affect the terms and conditions related to the amount, duration or scope of mental health benefits except for aggregate lifetime limits and annual limits; (4) This subsection (g) shall not apply to group health plans issued to small employers, defined as those with from two (2) to fifty (50) employees; (5) This subsection (g) shall not apply if its application results in an increase in the cost of the coverage of at least one percent (1%); (6) If the group health plan offers a participant two (2) or more benefit package options, this subsection (g) shall be applied separately to each option; (7) For purposes of this subsection (g), "mental health benefits" does not include benefits for the treatment of substance abuse or chemical dependency; (8) This subsection (g) shall not apply to benefits for services furnished on or after September 30, 2001; and (9) The commissioner may promulgate reasonable rules and regulations necessary for the proper administration of this subsection (g). Amended by 2024 Tenn. Acts, ch. 949,s 8, eff. 7/1/2024. Amended by 2024 Tenn. Acts, ch. 949,s 7, eff. 7/1/2024. Amended by 2024 Tenn. Acts, ch. 949,s 6, eff. 7/1/2024. Acts 1974, ch. 482, § 1; 1979, ch. 252, § 1; T.C.A., § 56-1167; Acts 1980, ch. 570, §§ 1, 2; 1981, ch. 285, §§ 1, 2; 1982, ch. 821, § 1; 1984, ch. 946, §§ 1, 2; 1992, ch. 984, § 4; 1992, ch. 991, §§ 20, 21; T.C.A., § 56-7-1003 ; Acts 1997 , ch. 157, § 17; 1998, ch. 1042, §§ 2, 3; 2000, ch. 947, §§ 6, 8F, 8L; 2010 , ch. 1100, §§ 93, 94; 2011 , ch. 158, § 30; 2012 , ch. 575, § 1.
(a) As used in this section: (1) "Annual limit" means a dollar limitation on the total amount that may be paid for benefits in a twelve-month period under a health plan with respect to an individual or other coverage unit; (2) "Clinical staff" means an individual on the community mental health center staff who performs as a part of the treatment team diagnostic and/or counseling services and who holds at least a master's degree in either of the disciplines of psychology, nursing, or social work and any required license; and (3) "Community mental health center" means a private entity qualified as a tax exempt organization under § 501(c)(3) of the Internal Revenue Code ( 26 U.S.C. § 501(c)(3) ), or a public entity created by private act of the general assembly that: (A) Is primarily engaged in providing services for the diagnosis and treatment of emotionally disturbed and mentally ill persons, has a requirement that all mental health care be under a treatment plan approved and reviewed by a licensed physician or a licensed psychologist designated as a health care service provider, and has appropriate arrangements to assure that patients requiring medical services can be referred to a physician or hospital; and (B) Has been licensed as a mental health clinic facility by the department of mental health and substance abuse services, or by the licensing board of the state in which the community mental health center is located.
(1) "Annual limit" means a dollar limitation on the total amount that may be paid for benefits in a twelve-month period under a health plan with respect to an individual or other coverage unit;
(2) "Clinical staff" means an individual on the community mental health center staff who performs as a part of the treatment team diagnostic and/or counseling services and who holds at least a master's degree in either of the disciplines of psychology, nursing, or social work and any required license; and
(3) "Community mental health center" means a private entity qualified as a tax exempt organization under § 501(c)(3) of the Internal Revenue Code ( 26 U.S.C. § 501(c)(3) ), or a public entity created by private act of the general assembly that: (A) Is primarily engaged in providing services for the diagnosis and treatment of emotionally disturbed and mentally ill persons, has a requirement that all mental health care be under a treatment plan approved and reviewed by a licensed physician or a licensed psychologist designated as a health care service provider, and has appropriate arrangements to assure that patients requiring medical services can be referred to a physician or hospital; and (B) Has been licensed as a mental health clinic facility by the department of mental health and substance abuse services, or by the licensing board of the state in which the community mental health center is located.
(A) Is primarily engaged in providing services for the diagnosis and treatment of emotionally disturbed and mentally ill persons, has a requirement that all mental health care be under a treatment plan approved and reviewed by a licensed physician or a licensed psychologist designated as a health care service provider, and has appropriate arrangements to assure that patients requiring medical services can be referred to a physician or hospital; and
(B) Has been licensed as a mental health clinic facility by the department of mental health and substance abuse services, or by the licensing board of the state in which the community mental health center is located.
(b) All other laws of this state notwithstanding, any individual, franchise, blanket or group policy of insurance issued pursuant to this title that provides hospital expense and surgical expense insurance and that is entered into, delivered, issued for delivery, or renewed, excepting individual insurance policy renewal, by agreement or otherwise, commencing on July 1, 1974, shall provide benefits for expense of residents of this state covered under the policy or plan, arising from psychiatric disorders, mental or nervous conditions, as described and defined in the Diagnostic Standard Manual of the American Psychiatric Association, alcoholism, drug dependence, both defined as mental illness in § 33-1-101 , or the medical complication of mental illness or intellectual disability, unless the policy or plan of insurance, excluding a TennCare health benefit plan, specifically excludes or reduces these benefits. This subsection (b) shall not apply to group policies or plans to which § 56-7-2360 applies. The medical and hospital benefits and coverage provided for the disorders, conditions and complications, if any, shall not be denied because of confinement in a particular facility; provided, that the facility is either: (1) A hospital licensed under title 33, chapter 2 or title 68, chapter 11, part 2, and accredited by the joint commission on the accreditation of hospitals; or (2) A hospital owned or operated by the state that is especially intended for use in the diagnosis, care and treatment of psychiatric, mental or nervous disorders, nor shall the benefits and coverage be denied on the basis that physician's services were performed by physicians not on the staff of a particular facility, so long as those services were rendered while insureds were hospitalized in that facility.
(1) A hospital licensed under title 33, chapter 2 or title 68, chapter 11, part 2, and accredited by the joint commission on the accreditation of hospitals; or
(2) A hospital owned or operated by the state that is especially intended for use in the diagnosis, care and treatment of psychiatric, mental or nervous disorders, nor shall the benefits and coverage be denied on the basis that physician's services were performed by physicians not on the staff of a particular facility, so long as those services were rendered while insureds were hospitalized in that facility.
(c) (1) After July 1, 1980, every insurer that proposes to issue a group hospital policy or a group major medical policy in this state and every nonprofit hospital and medical service plan corporation that proposes to issue group hospital, medical or major medical service plan contracts that provide coverage for the insured or the subscriber shall, in the case of outpatient expenses at a community mental health center, make available benefits as specified in this section for the care and treatment of mental, emotional or nervous disorders, alcoholism, drug dependence or the medical complication of mental illness or intellectual disability. (2) The benefits required to be made available by this subsection (c) shall be a part of each group policy or group contract described in this section, unless the policyholder or group contract subscriber rejects in writing the coverage. (3) (A) When benefits as specified in this section are made available for treatment received at the community mental health center, the benefits that cover services rendered by a physician in accordance with the policy or service plan contract shall also be made available when services are rendered by a member of the clinical staff, so long as the community mental health center has in effect a plan for quality assurance approved by the department of mental health and substance abuse services and the treatment is supervised by a licensed physician or a licensed psychologist designated as a health service provider. However, nothing in this subsection (c) may be construed to affect the license of a physician or psychologist designated as a health service provider providing the service or supervision. The benefits shall be provided at the usual and customary rates established by the community mental health center for the services rendered. However, the benefits provided shall be subject to deductibles and coinsurance factors that are not less favorable than for physical illness generally, and in no event shall coverage be required to be made available for more than thirty (30) outpatient visits per year. (B) With respect to benefits provided under subdivision (c)(3)(A) by a TennCare health benefit plan, the benefits provided are subject to deductibles and coinsurance factors that are not less favorable than for physical illness or the treatment of alcoholism or substance abuse generally, and coverage and reimbursement are not required to be made available for more than the number of visits per year offered for the treatment of alcoholism or substance abuse.
(1) After July 1, 1980, every insurer that proposes to issue a group hospital policy or a group major medical policy in this state and every nonprofit hospital and medical service plan corporation that proposes to issue group hospital, medical or major medical service plan contracts that provide coverage for the insured or the subscriber shall, in the case of outpatient expenses at a community mental health center, make available benefits as specified in this section for the care and treatment of mental, emotional or nervous disorders, alcoholism, drug dependence or the medical complication of mental illness or intellectual disability.
(2) The benefits required to be made available by this subsection (c) shall be a part of each group policy or group contract described in this section, unless the policyholder or group contract subscriber rejects in writing the coverage.
(3) (A) When benefits as specified in this section are made available for treatment received at the community mental health center, the benefits that cover services rendered by a physician in accordance with the policy or service plan contract shall also be made available when services are rendered by a member of the clinical staff, so long as the community mental health center has in effect a plan for quality assurance approved by the department of mental health and substance abuse services and the treatment is supervised by a licensed physician or a licensed psychologist designated as a health service provider. However, nothing in this subsection (c) may be construed to affect the license of a physician or psychologist designated as a health service provider providing the service or supervision. The benefits shall be provided at the usual and customary rates established by the community mental health center for the services rendered. However, the benefits provided shall be subject to deductibles and coinsurance factors that are not less favorable than for physical illness generally, and in no event shall coverage be required to be made available for more than thirty (30) outpatient visits per year. (B) With respect to benefits provided under subdivision (c)(3)(A) by a TennCare health benefit plan, the benefits provided are subject to deductibles and coinsurance factors that are not less favorable than for physical illness or the treatment of alcoholism or substance abuse generally, and coverage and reimbursement are not required to be made available for more than the number of visits per year offered for the treatment of alcoholism or substance abuse.
(A) When benefits as specified in this section are made available for treatment received at the community mental health center, the benefits that cover services rendered by a physician in accordance with the policy or service plan contract shall also be made available when services are rendered by a member of the clinical staff, so long as the community mental health center has in effect a plan for quality assurance approved by the department of mental health and substance abuse services and the treatment is supervised by a licensed physician or a licensed psychologist designated as a health service provider. However, nothing in this subsection (c) may be construed to affect the license of a physician or psychologist designated as a health service provider providing the service or supervision. The benefits shall be provided at the usual and customary rates established by the community mental health center for the services rendered. However, the benefits provided shall be subject to deductibles and coinsurance factors that are not less favorable than for physical illness generally, and in no event shall coverage be required to be made available for more than thirty (30) outpatient visits per year.
(B) With respect to benefits provided under subdivision (c)(3)(A) by a TennCare health benefit plan, the benefits provided are subject to deductibles and coinsurance factors that are not less favorable than for physical illness or the treatment of alcoholism or substance abuse generally, and coverage and reimbursement are not required to be made available for more than the number of visits per year offered for the treatment of alcoholism or substance abuse.
(d) With respect to policies and contracts as described in subsection (c) that are delivered or issued for delivery in this state on or before July 1, 1980, each insurer and nonprofit hospital and medical service plan corporation shall notify the group policyholder or group contract holder of the availability of coverage described in subsection (c). The notification shall describe the benefits available and shall provide a means by which the policyholder or group contract holder may communicate acceptance or rejection of the coverage.
(e) All group hospital and major medical policies delivered or issued for delivery in this state after July 1, 1980, and all group hospital, medical and major medical service plans commencing in this state after July 1, 1980, that provide benefits for expenses of residents of the state arising from psychiatric disorders, mental or nervous conditions, alcoholism, drug dependence or medical complication of mental illness or intellectual disability, shall reimburse for these benefits, if any, when the benefits are provided at a facility that is: (1) With respect to outpatient benefit, a community mental health center; (2) With respect to inpatient benefits, a community mental health center that has facilities for inpatient care and that has received a certificate of need from the Tennessee health facilities commission certifying the necessity of the facility if required by law; or (3) For persons covered under a TennCare health benefit plan, a residential or other mental health treatment facility licensed under title 33, chapter 2, part 4.
(1) With respect to outpatient benefit, a community mental health center;
(2) With respect to inpatient benefits, a community mental health center that has facilities for inpatient care and that has received a certificate of need from the Tennessee health facilities commission certifying the necessity of the facility if required by law; or
(3) For persons covered under a TennCare health benefit plan, a residential or other mental health treatment facility licensed under title 33, chapter 2, part 4.
(f) All individual, franchise, blanket, or group policies of insurance issued pursuant to this title that provide hospital expense and medical or surgical expense insurance and that are entered into, delivered, issued for delivery, or renewed, except individual insurance policy renewal, by agreement or otherwise, commencing on July 1, 1981, and that provide benefits for expenses of residents of the state arising from alcoholism, drug dependence or medical complication resulting from alcoholism, or drug dependence shall reimburse for these benefits, if any, when the benefits are provided at a facility that is a residential treatment facility licensed under title 33, chapter 2, part 4, and accredited by the joint commission on the accreditation of hospitals.
(g) Subject to § 56-7-2360 , in general, with respect to group health plans issued by entities regulated pursuant to insurance law, for plan years beginning on or after January 1, 1998, certain mental health benefits are required as follows: (1) As to either aggregate lifetime limits or annual limits or both, for a group health plan providing both medical and surgical benefits and mental health benefits: (A) If the plan does not have a limit on substantially all medical and surgical benefits, the plan may not impose such a limit on mental health benefits; (B) If the plan has a limit on substantially all medical and surgical benefits, the plan shall either include mental health benefits under the limit applied to medical and surgical benefits or apply a separate limit to mental health benefits that is no less than the one applied to medical and surgical benefits; and (C) If the plan has varying limits on different medical or surgical benefits, the plan shall apply an average limit to mental health benefits with the average to be computed based on the weighted average of the varying limits; (2) No group health plan is required under this subsection (g) to provide mental health benefits; (3) This subsection (g) shall not affect the terms and conditions related to the amount, duration or scope of mental health benefits except for aggregate lifetime limits and annual limits; (4) This subsection (g) shall not apply to group health plans issued to small employers, defined as those with from two (2) to fifty (50) employees; (5) This subsection (g) shall not apply if its application results in an increase in the cost of the coverage of at least one percent (1%); (6) If the group health plan offers a participant two (2) or more benefit package options, this subsection (g) shall be applied separately to each option; (7) For purposes of this subsection (g), "mental health benefits" does not include benefits for the treatment of substance abuse or chemical dependency; (8) This subsection (g) shall not apply to benefits for services furnished on or after September 30, 2001; and (9) The commissioner may promulgate reasonable rules and regulations necessary for the proper administration of this subsection (g).
(1) As to either aggregate lifetime limits or annual limits or both, for a group health plan providing both medical and surgical benefits and mental health benefits: (A) If the plan does not have a limit on substantially all medical and surgical benefits, the plan may not impose such a limit on mental health benefits; (B) If the plan has a limit on substantially all medical and surgical benefits, the plan shall either include mental health benefits under the limit applied to medical and surgical benefits or apply a separate limit to mental health benefits that is no less than the one applied to medical and surgical benefits; and (C) If the plan has varying limits on different medical or surgical benefits, the plan shall apply an average limit to mental health benefits with the average to be computed based on the weighted average of the varying limits;
(A) If the plan does not have a limit on substantially all medical and surgical benefits, the plan may not impose such a limit on mental health benefits;
(B) If the plan has a limit on substantially all medical and surgical benefits, the plan shall either include mental health benefits under the limit applied to medical and surgical benefits or apply a separate limit to mental health benefits that is no less than the one applied to medical and surgical benefits; and
(C) If the plan has varying limits on different medical or surgical benefits, the plan shall apply an average limit to mental health benefits with the average to be computed based on the weighted average of the varying limits;
(2) No group health plan is required under this subsection (g) to provide mental health benefits;
(3) This subsection (g) shall not affect the terms and conditions related to the amount, duration or scope of mental health benefits except for aggregate lifetime limits and annual limits;
(4) This subsection (g) shall not apply to group health plans issued to small employers, defined as those with from two (2) to fifty (50) employees;
(5) This subsection (g) shall not apply if its application results in an increase in the cost of the coverage of at least one percent (1%);
(6) If the group health plan offers a participant two (2) or more benefit package options, this subsection (g) shall be applied separately to each option;
(7) For purposes of this subsection (g), "mental health benefits" does not include benefits for the treatment of substance abuse or chemical dependency;
(8) This subsection (g) shall not apply to benefits for services furnished on or after September 30, 2001; and
(9) The commissioner may promulgate reasonable rules and regulations necessary for the proper administration of this subsection (g).
Amended by 2024 Tenn. Acts, ch. 949,s 8, eff. 7/1/2024.
Amended by 2024 Tenn. Acts, ch. 949,s 7, eff. 7/1/2024.
Amended by 2024 Tenn. Acts, ch. 949,s 6, eff. 7/1/2024.
Acts 1974, ch. 482, § 1; 1979, ch. 252, § 1; T.C.A., § 56-1167; Acts 1980, ch. 570, §§ 1, 2; 1981, ch. 285, §§ 1, 2; 1982, ch. 821, § 1; 1984, ch. 946, §§ 1, 2; 1992, ch. 984, § 4; 1992, ch. 991, §§ 20, 21; T.C.A., § 56-7-1003 ; Acts 1997 , ch. 157, § 17; 1998, ch. 1042, §§ 2, 3; 2000, ch. 947, §§ 6, 8F, 8L; 2010 , ch. 1100, §§ 93, 94; 2011 , ch. 158, § 30; 2012 , ch. 575, § 1.
Tenn. Code Ann. § 56-7-2360 — TN Code / Title 56 / Chapter 7 / Section 56-7-2360
Coverage for mental health, alcoholism, or drug dependency services
Status: in_force

(a) (1) As used in this section: (A) "Aggregate lifetime limit" means a dollar limitation on the total amount that may be paid for benefits under a health plan with respect to an individual or other coverage unit; (B) "Annual limit" means a dollar limitation on the total amount that may be paid for benefits in a twelve-month period under a health plan with respect to an individual or other coverage unit; (C) "Classification of benefits" means: (i) Inpatient in-network benefits, inpatient out-of-network benefits, outpatient in-network benefits, outpatient out-of-network benefits, prescription drug benefits, and emergency care benefits; and (ii) The only classifications that may be used, except that there may be sub-classifications within both outpatient classifications differentiating office visits from other outpatient items and services, including outpatient surgery, facility charges for day treatment centers, laboratory charges, and other medical items; (D) "Financial requirement" includes deductibles, copayments, coinsurance, and out-of-pocket expenses, but excludes an aggregate lifetime limit and an annual limit; (E) "Health benefit plan" means a hospital or medical expense policy, health, hospital, or medical service corporation contract, a policy or agreement entered into by a health insurer or a health maintenance organization contract offered by an employer, other plans administered by the state government, or a certificate issued under the policies, contracts, or plans; (F) "Health insurance carrier" means an entity subject to this title, or subject to the jurisdiction of the commissioner of commerce and insurance, that contracts with healthcare providers in connection with a plan of health insurance, health benefits, or health services; (G) "Mental health or alcoholism or drug dependency benefits" means benefits for the treatment of a condition or disorder that involves a mental health condition or substance use disorder that: (i) Falls under the diagnostic categories listed in the mental disorders section of the current edition of the International Classification of Disease; or (ii) Is listed in the mental disorders section of the most recent version of the Diagnostic and Statistical Manual of Mental Disorders; (H) "Non-quantitative treatment limitations" or "NQTLs": (i) Means limitations that are not expressed numerically, but otherwise limit the scope or duration of benefits for treatment. For purposes of this subdivision (a)(1)(H), fail-first or step therapy protocols do not include formulary designs that require the prescription, use, and a showing of ineffectiveness of generic drugs prior to approval of payment for the prescription of higher cost drugs; and (ii) Include: (a) Medical management standards limiting or excluding benefits based on medical necessity or medical appropriateness, or based on whether the treatment is experimental or investigative; (b) Formulary design for prescription drugs; (c) Tier design for plans with multiple network tiers, including preferred providers and participating providers, and network tier design; (d) Standards for provider admission to participate in a network, including reimbursement rates; (e) Plan methods for determining usual, customary, and reasonable charges; (f) Refusal to pay for higher-cost therapies until it can be shown that a lower-cost therapy is not effective, that are also known as fail-first policies or step therapy protocols; (g) Exclusions based on failure to complete a course of treatment; (h) Restrictions based on geographic location, facility type, provider specialty, and other criteria that limit the scope or duration of benefits for services provided under the plan or coverage; (i) In- and out-of-network geographic limitations; (j) Standards for providing access to out-of-network providers; (k) Limitations on inpatient services for situations where the participant is a threat to self or others; (l) Exclusions for court-ordered and involuntary holds; (m) Experimental treatment limitations; (n) Service coding; and (o) Exclusions for services provided by clinical social workers; (I) "Predominant" means application to more than one-half (1/2) of such type of limit or requirement; (J) "Substantially all" means application to at least two-thirds (2/3) of all medical or surgical benefits in a classification; and (K) "Treatment limitation" includes limits on the frequency of treatment, number of visits, days of coverage, or other similar limits on the scope or duration of treatment. (2) In addition to any other requirement of law concerning coverage of mental health or mental illness benefits or alcoholism or drug dependency benefits, including, but not limited to, §§ 56-7-2601 and 56-7-2602 , an individual or group health benefit plan issued by a health insurance carrier regulated pursuant to this title or title 71, chapter 5 shall provide coverage for mental health or alcoholism or drug dependency services in compliance with the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) ( 42 U.S.C. § 300gg-26 ) and 45 CFR § 146.136 and 45 CFR § 147.160 . (b) Subsection (a) does not prohibit an employee health benefit plan, or a plan issuer offering an individual or group health plan from utilizing managed care practices for the delivery of benefits required under this section, as long as that for an utilization review or benefit determination for the treatment of alcoholism or drug dependence the clinical review criteria is the most recent Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions established by the American Society of Addiction Medicine or other evidence-based clinical guidelines, such as those referenced by the federal substance abuse and mental health services administration (SAMHSA). Additional criteria, other than in this subsection (b), must not be used during utilization review or benefit determination for treatment of substance use disorders; provided, that for purposes of a TennCare health benefit plan, additional criteria used must ensure that benefit determination, including coverage and reimbursement for the treatment of alcoholism or drug dependence, remain in parity with benefit determination for the treatment of mental health disorders. (c) The mandate to provide coverage for mental health services does not apply with respect to a group health plan if the application of the mandate to the plan results in an increase in the cost under the plan of more than one percent (1%). Documentation of the increase in cost must be filed with the department after twelve (12) months of experience. If the commissioner determines that the increase in cost is a result of the requirements of this section, then the commissioner or the commissioner's designee shall issue a letter to the issuer of the plan stating that the plan does not have to comply with the mandate set out in this section. The issuer may appeal the letter as final agency action pursuant to the Uniform Administrative Procedures Act, compiled in title 4, chapter 5. (d) The department of commerce and insurance shall implement and enforce applicable provisions of the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, this section, and §§ 56-7-2601 and 56-7-2602 , that include: (1) Ensuring compliance by individual and group health benefit plans; (2) Detecting possible violations of the law by individual and group health benefit plans; (3) Accepting, evaluating, and responding to complaints regarding such violations; and (4) Maintaining and regularly reviewing for possible parity violations a publicly available consumer complaint log regarding mental health or alcoholism or drug dependency coverage as long as individually identifiable information is excluded. (e) Not later than January 31, 2022, and each year thereafter, the department shall issue a report to the general assembly and provide an educational presentation to the general assembly. The department shall request from the United States department of labor and the United States department of health and human services copies of the NQTL analyses submitted to the departments the previous year in compliance with the federal Consolidated Appropriations Act of 2021 (Pub.L. 116-260) and incorporate these analyses into the report. The report and presentation must: (1) List health plans sold in this state and over which of these plans the department has jurisdiction; (2) Discuss the methodology the department is using to check for compliance with the MHPAEA, and any federal regulations or guidance relating to the compliance and oversight of the MHPAEA, including 45 CFR 146.136 ; (3) Discuss the methodology the department uses to check for compliance with this section and §§ 56-7-2601 and 56-7-2602 ; (4) Identify market conduct examinations and full scope examinations conducted or completed during the preceding twelve-month period and summarize the results of the examinations. Individually identifiable information must be excluded from the reports consistent with federal privacy protections, including, but not limited to, 42 U.S.C. § 290dd-2 and regulations found at 42 CFR § 2.1 through 42 CFR § 2.67 . This discussion must include: (A) The number of full scope examinations and market conduct examinations initiated and completed; (B) The benefit classifications examined by each market conduct examination and full scope examination; (C) The subject matter of each market conduct examination, including quantitative and non-quantitative treatment limitations; (D) A summary of the basis for the final decision rendered in each market conduct examination; and (E) A detailed explanation regarding parity in coverage and rates of reimbursement for mental health services and alcoholism and drug dependency services in compliance with this title and § 71-5-171(b); (5) Detail educational or corrective actions the department of commerce and insurance has taken to ensure health benefit plan compliance with this section, the MHPAEA, 42 U.S.C. § 18031(j) , and §§ 56-7-2601 and 56-7-2602 ; (6) Detail the department's educational approaches relating to informing the public about mental health or alcoholism or drug dependence parity protections under state and federal law; and (7) Describe how the department examines any provider or consumer complaints related to denials or restrictions for possible violations of this section, the MHPAEA, 42 U.S.C. § 18031(j) , and §§ 56-7-2601 and 56-7-2602 , including complaints regarding, but not limited to: (A) Denials of claims for residential treatment or other inpatient treatment on the grounds that such a level of care is not medically necessary; (B) Claims for residential treatment or other inpatient treatment that were approved but for a fewer number of days than requested; (C) Denials of requests, authorizations, pre-authorizations, prior authorizations, concurrent reviews, or claims for residential treatment or other inpatient treatment because the beneficiary had not first attempted outpatient treatment, medication, or a combination of outpatient treatment and medication; (D) Denials of claims for medications such as buprenorphine or naltrexone on the grounds that they are not medically necessary; (E) Step therapy requirements imposed before buprenorphine or naltrexone are approved; (F) Prior authorization requirements imposed on claims for buprenorphine or naltrexone, including those imposed because of safety risks associated with buprenorphine; and (G) Denial of in-network authorization or denials of out-of-network services or claims where there is not an in-network provider within seventy-five (75) miles of the insured patient's home. (f) The report issued pursuant to subsection (e) must be written in non-technical, readily understandable language and be made available to the public by posting the report on the department's website and by other means as the department finds appropriate. The name and identity of the health insurance carrier must be given confidential treatment, may not be made public by the commissioner or another person, and are not subject to public inspection pursuant to § 10-7-503 . (g) Benefits under this section shall not be denied for care for confinement provided in a hospital owned or operated by this state that is especially intended for use in the diagnosis, care, and treatment of psychiatric, mental, or nervous disorders. (h) This section does not apply to accident-only, specified disease, hospital indemnity, medicare supplement, long-term care, or other limited benefit hospital insurance policies. (i) The commissioner is authorized to promulgate rules to effectuate the purposes of this section. The rules must be promulgated in accordance with the Uniform Administrative Procedures Act, compiled in title 4, chapter 5. (j) This section does not require the disclosure of information that would violate 42 U.S.C. § 290dd-2 and regulations found at 42 CFR § 2.1 through 42 CFR § 2.67 . Amended by 2024 Tenn. Acts, ch. 949,s 5, eff. 7/1/2024. Amended by 2024 Tenn. Acts, ch. 949,s 4, eff. 7/1/2024. Amended by 2024 Tenn. Acts, ch. 949,s 3, eff. 7/1/2024. Amended by 2021 Tenn. Acts, ch. 244, s 1, eff. 4/28/2021. Amended by 2018 Tenn. Acts, ch. 1012, s 1, eff. 1/1/2019. Acts 1998, ch. 1042, §§ 1, 4.
(a) (1) As used in this section: (A) "Aggregate lifetime limit" means a dollar limitation on the total amount that may be paid for benefits under a health plan with respect to an individual or other coverage unit; (B) "Annual limit" means a dollar limitation on the total amount that may be paid for benefits in a twelve-month period under a health plan with respect to an individual or other coverage unit; (C) "Classification of benefits" means: (i) Inpatient in-network benefits, inpatient out-of-network benefits, outpatient in-network benefits, outpatient out-of-network benefits, prescription drug benefits, and emergency care benefits; and (ii) The only classifications that may be used, except that there may be sub-classifications within both outpatient classifications differentiating office visits from other outpatient items and services, including outpatient surgery, facility charges for day treatment centers, laboratory charges, and other medical items; (D) "Financial requirement" includes deductibles, copayments, coinsurance, and out-of-pocket expenses, but excludes an aggregate lifetime limit and an annual limit; (E) "Health benefit plan" means a hospital or medical expense policy, health, hospital, or medical service corporation contract, a policy or agreement entered into by a health insurer or a health maintenance organization contract offered by an employer, other plans administered by the state government, or a certificate issued under the policies, contracts, or plans; (F) "Health insurance carrier" means an entity subject to this title, or subject to the jurisdiction of the commissioner of commerce and insurance, that contracts with healthcare providers in connection with a plan of health insurance, health benefits, or health services; (G) "Mental health or alcoholism or drug dependency benefits" means benefits for the treatment of a condition or disorder that involves a mental health condition or substance use disorder that: (i) Falls under the diagnostic categories listed in the mental disorders section of the current edition of the International Classification of Disease; or (ii) Is listed in the mental disorders section of the most recent version of the Diagnostic and Statistical Manual of Mental Disorders; (H) "Non-quantitative treatment limitations" or "NQTLs": (i) Means limitations that are not expressed numerically, but otherwise limit the scope or duration of benefits for treatment. For purposes of this subdivision (a)(1)(H), fail-first or step therapy protocols do not include formulary designs that require the prescription, use, and a showing of ineffectiveness of generic drugs prior to approval of payment for the prescription of higher cost drugs; and (ii) Include: (a) Medical management standards limiting or excluding benefits based on medical necessity or medical appropriateness, or based on whether the treatment is experimental or investigative; (b) Formulary design for prescription drugs; (c) Tier design for plans with multiple network tiers, including preferred providers and participating providers, and network tier design; (d) Standards for provider admission to participate in a network, including reimbursement rates; (e) Plan methods for determining usual, customary, and reasonable charges; (f) Refusal to pay for higher-cost therapies until it can be shown that a lower-cost therapy is not effective, that are also known as fail-first policies or step therapy protocols; (g) Exclusions based on failure to complete a course of treatment; (h) Restrictions based on geographic location, facility type, provider specialty, and other criteria that limit the scope or duration of benefits for services provided under the plan or coverage; (i) In- and out-of-network geographic limitations; (j) Standards for providing access to out-of-network providers; (k) Limitations on inpatient services for situations where the participant is a threat to self or others; (l) Exclusions for court-ordered and involuntary holds; (m) Experimental treatment limitations; (n) Service coding; and (o) Exclusions for services provided by clinical social workers; (I) "Predominant" means application to more than one-half (1/2) of such type of limit or requirement; (J) "Substantially all" means application to at least two-thirds (2/3) of all medical or surgical benefits in a classification; and (K) "Treatment limitation" includes limits on the frequency of treatment, number of visits, days of coverage, or other similar limits on the scope or duration of treatment. (2) In addition to any other requirement of law concerning coverage of mental health or mental illness benefits or alcoholism or drug dependency benefits, including, but not limited to, §§ 56-7-2601 and 56-7-2602 , an individual or group health benefit plan issued by a health insurance carrier regulated pursuant to this title or title 71, chapter 5 shall provide coverage for mental health or alcoholism or drug dependency services in compliance with the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) ( 42 U.S.C. § 300gg-26 ) and 45 CFR § 146.136 and 45 CFR § 147.160 .
(1) As used in this section: (A) "Aggregate lifetime limit" means a dollar limitation on the total amount that may be paid for benefits under a health plan with respect to an individual or other coverage unit; (B) "Annual limit" means a dollar limitation on the total amount that may be paid for benefits in a twelve-month period under a health plan with respect to an individual or other coverage unit; (C) "Classification of benefits" means: (i) Inpatient in-network benefits, inpatient out-of-network benefits, outpatient in-network benefits, outpatient out-of-network benefits, prescription drug benefits, and emergency care benefits; and (ii) The only classifications that may be used, except that there may be sub-classifications within both outpatient classifications differentiating office visits from other outpatient items and services, including outpatient surgery, facility charges for day treatment centers, laboratory charges, and other medical items; (D) "Financial requirement" includes deductibles, copayments, coinsurance, and out-of-pocket expenses, but excludes an aggregate lifetime limit and an annual limit; (E) "Health benefit plan" means a hospital or medical expense policy, health, hospital, or medical service corporation contract, a policy or agreement entered into by a health insurer or a health maintenance organization contract offered by an employer, other plans administered by the state government, or a certificate issued under the policies, contracts, or plans; (F) "Health insurance carrier" means an entity subject to this title, or subject to the jurisdiction of the commissioner of commerce and insurance, that contracts with healthcare providers in connection with a plan of health insurance, health benefits, or health services; (G) "Mental health or alcoholism or drug dependency benefits" means benefits for the treatment of a condition or disorder that involves a mental health condition or substance use disorder that: (i) Falls under the diagnostic categories listed in the mental disorders section of the current edition of the International Classification of Disease; or (ii) Is listed in the mental disorders section of the most recent version of the Diagnostic and Statistical Manual of Mental Disorders; (H) "Non-quantitative treatment limitations" or "NQTLs": (i) Means limitations that are not expressed numerically, but otherwise limit the scope or duration of benefits for treatment. For purposes of this subdivision (a)(1)(H), fail-first or step therapy protocols do not include formulary designs that require the prescription, use, and a showing of ineffectiveness of generic drugs prior to approval of payment for the prescription of higher cost drugs; and (ii) Include: (a) Medical management standards limiting or excluding benefits based on medical necessity or medical appropriateness, or based on whether the treatment is experimental or investigative; (b) Formulary design for prescription drugs; (c) Tier design for plans with multiple network tiers, including preferred providers and participating providers, and network tier design; (d) Standards for provider admission to participate in a network, including reimbursement rates; (e) Plan methods for determining usual, customary, and reasonable charges; (f) Refusal to pay for higher-cost therapies until it can be shown that a lower-cost therapy is not effective, that are also known as fail-first policies or step therapy protocols; (g) Exclusions based on failure to complete a course of treatment; (h) Restrictions based on geographic location, facility type, provider specialty, and other criteria that limit the scope or duration of benefits for services provided under the plan or coverage; (i) In- and out-of-network geographic limitations; (j) Standards for providing access to out-of-network providers; (k) Limitations on inpatient services for situations where the participant is a threat to self or others; (l) Exclusions for court-ordered and involuntary holds; (m) Experimental treatment limitations; (n) Service coding; and (o) Exclusions for services provided by clinical social workers; (I) "Predominant" means application to more than one-half (1/2) of such type of limit or requirement; (J) "Substantially all" means application to at least two-thirds (2/3) of all medical or surgical benefits in a classification; and (K) "Treatment limitation" includes limits on the frequency of treatment, number of visits, days of coverage, or other similar limits on the scope or duration of treatment.
(A) "Aggregate lifetime limit" means a dollar limitation on the total amount that may be paid for benefits under a health plan with respect to an individual or other coverage unit;
(B) "Annual limit" means a dollar limitation on the total amount that may be paid for benefits in a twelve-month period under a health plan with respect to an individual or other coverage unit;
(C) "Classification of benefits" means: (i) Inpatient in-network benefits, inpatient out-of-network benefits, outpatient in-network benefits, outpatient out-of-network benefits, prescription drug benefits, and emergency care benefits; and (ii) The only classifications that may be used, except that there may be sub-classifications within both outpatient classifications differentiating office visits from other outpatient items and services, including outpatient surgery, facility charges for day treatment centers, laboratory charges, and other medical items;
(i) Inpatient in-network benefits, inpatient out-of-network benefits, outpatient in-network benefits, outpatient out-of-network benefits, prescription drug benefits, and emergency care benefits; and
(ii) The only classifications that may be used, except that there may be sub-classifications within both outpatient classifications differentiating office visits from other outpatient items and services, including outpatient surgery, facility charges for day treatment centers, laboratory charges, and other medical items;
(D) "Financial requirement" includes deductibles, copayments, coinsurance, and out-of-pocket expenses, but excludes an aggregate lifetime limit and an annual limit;
(E) "Health benefit plan" means a hospital or medical expense policy, health, hospital, or medical service corporation contract, a policy or agreement entered into by a health insurer or a health maintenance organization contract offered by an employer, other plans administered by the state government, or a certificate issued under the policies, contracts, or plans;
(F) "Health insurance carrier" means an entity subject to this title, or subject to the jurisdiction of the commissioner of commerce and insurance, that contracts with healthcare providers in connection with a plan of health insurance, health benefits, or health services;
(G) "Mental health or alcoholism or drug dependency benefits" means benefits for the treatment of a condition or disorder that involves a mental health condition or substance use disorder that: (i) Falls under the diagnostic categories listed in the mental disorders section of the current edition of the International Classification of Disease; or (ii) Is listed in the mental disorders section of the most recent version of the Diagnostic and Statistical Manual of Mental Disorders;
(i) Falls under the diagnostic categories listed in the mental disorders section of the current edition of the International Classification of Disease; or
(ii) Is listed in the mental disorders section of the most recent version of the Diagnostic and Statistical Manual of Mental Disorders;
(H) "Non-quantitative treatment limitations" or "NQTLs": (i) Means limitations that are not expressed numerically, but otherwise limit the scope or duration of benefits for treatment. For purposes of this subdivision (a)(1)(H), fail-first or step therapy protocols do not include formulary designs that require the prescription, use, and a showing of ineffectiveness of generic drugs prior to approval of payment for the prescription of higher cost drugs; and (ii) Include: (a) Medical management standards limiting or excluding benefits based on medical necessity or medical appropriateness, or based on whether the treatment is experimental or investigative; (b) Formulary design for prescription drugs; (c) Tier design for plans with multiple network tiers, including preferred providers and participating providers, and network tier design; (d) Standards for provider admission to participate in a network, including reimbursement rates; (e) Plan methods for determining usual, customary, and reasonable charges; (f) Refusal to pay for higher-cost therapies until it can be shown that a lower-cost therapy is not effective, that are also known as fail-first policies or step therapy protocols; (g) Exclusions based on failure to complete a course of treatment; (h) Restrictions based on geographic location, facility type, provider specialty, and other criteria that limit the scope or duration of benefits for services provided under the plan or coverage; (i) In- and out-of-network geographic limitations; (j) Standards for providing access to out-of-network providers; (k) Limitations on inpatient services for situations where the participant is a threat to self or others; (l) Exclusions for court-ordered and involuntary holds; (m) Experimental treatment limitations; (n) Service coding; and (o) Exclusions for services provided by clinical social workers;
(i) Means limitations that are not expressed numerically, but otherwise limit the scope or duration of benefits for treatment. For purposes of this subdivision (a)(1)(H), fail-first or step therapy protocols do not include formulary designs that require the prescription, use, and a showing of ineffectiveness of generic drugs prior to approval of payment for the prescription of higher cost drugs; and
(ii) Include: (a) Medical management standards limiting or excluding benefits based on medical necessity or medical appropriateness, or based on whether the treatment is experimental or investigative; (b) Formulary design for prescription drugs; (c) Tier design for plans with multiple network tiers, including preferred providers and participating providers, and network tier design; (d) Standards for provider admission to participate in a network, including reimbursement rates; (e) Plan methods for determining usual, customary, and reasonable charges; (f) Refusal to pay for higher-cost therapies until it can be shown that a lower-cost therapy is not effective, that are also known as fail-first policies or step therapy protocols; (g) Exclusions based on failure to complete a course of treatment; (h) Restrictions based on geographic location, facility type, provider specialty, and other criteria that limit the scope or duration of benefits for services provided under the plan or coverage; (i) In- and out-of-network geographic limitations; (j) Standards for providing access to out-of-network providers; (k) Limitations on inpatient services for situations where the participant is a threat to self or others; (l) Exclusions for court-ordered and involuntary holds; (m) Experimental treatment limitations; (n) Service coding; and (o) Exclusions for services provided by clinical social workers;
(a) Medical management standards limiting or excluding benefits based on medical necessity or medical appropriateness, or based on whether the treatment is experimental or investigative;
(b) Formulary design for prescription drugs;
(c) Tier design for plans with multiple network tiers, including preferred providers and participating providers, and network tier design;
(d) Standards for provider admission to participate in a network, including reimbursement rates;
(e) Plan methods for determining usual, customary, and reasonable charges;
(f) Refusal to pay for higher-cost therapies until it can be shown that a lower-cost therapy is not effective, that are also known as fail-first policies or step therapy protocols;
(g) Exclusions based on failure to complete a course of treatment;
(h) Restrictions based on geographic location, facility type, provider specialty, and other criteria that limit the scope or duration of benefits for services provided under the plan or coverage;
(i) In- and out-of-network geographic limitations;
(j) Standards for providing access to out-of-network providers;
(k) Limitations on inpatient services for situations where the participant is a threat to self or others;
(l) Exclusions for court-ordered and involuntary holds;
(m) Experimental treatment limitations;
(n) Service coding; and
(o) Exclusions for services provided by clinical social workers;
(I) "Predominant" means application to more than one-half (1/2) of such type of limit or requirement;
(J) "Substantially all" means application to at least two-thirds (2/3) of all medical or surgical benefits in a classification; and
(K) "Treatment limitation" includes limits on the frequency of treatment, number of visits, days of coverage, or other similar limits on the scope or duration of treatment.
(2) In addition to any other requirement of law concerning coverage of mental health or mental illness benefits or alcoholism or drug dependency benefits, including, but not limited to, §§ 56-7-2601 and 56-7-2602 , an individual or group health benefit plan issued by a health insurance carrier regulated pursuant to this title or title 71, chapter 5 shall provide coverage for mental health or alcoholism or drug dependency services in compliance with the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) ( 42 U.S.C. § 300gg-26 ) and 45 CFR § 146.136 and 45 CFR § 147.160 .
(b) Subsection (a) does not prohibit an employee health benefit plan, or a plan issuer offering an individual or group health plan from utilizing managed care practices for the delivery of benefits required under this section, as long as that for an utilization review or benefit determination for the treatment of alcoholism or drug dependence the clinical review criteria is the most recent Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions established by the American Society of Addiction Medicine or other evidence-based clinical guidelines, such as those referenced by the federal substance abuse and mental health services administration (SAMHSA). Additional criteria, other than in this subsection (b), must not be used during utilization review or benefit determination for treatment of substance use disorders; provided, that for purposes of a TennCare health benefit plan, additional criteria used must ensure that benefit determination, including coverage and reimbursement for the treatment of alcoholism or drug dependence, remain in parity with benefit determination for the treatment of mental health disorders.
(c) The mandate to provide coverage for mental health services does not apply with respect to a group health plan if the application of the mandate to the plan results in an increase in the cost under the plan of more than one percent (1%). Documentation of the increase in cost must be filed with the department after twelve (12) months of experience. If the commissioner determines that the increase in cost is a result of the requirements of this section, then the commissioner or the commissioner's designee shall issue a letter to the issuer of the plan stating that the plan does not have to comply with the mandate set out in this section. The issuer may appeal the letter as final agency action pursuant to the Uniform Administrative Procedures Act, compiled in title 4, chapter 5.
(d) The department of commerce and insurance shall implement and enforce applicable provisions of the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, this section, and §§ 56-7-2601 and 56-7-2602 , that include: (1) Ensuring compliance by individual and group health benefit plans; (2) Detecting possible violations of the law by individual and group health benefit plans; (3) Accepting, evaluating, and responding to complaints regarding such violations; and (4) Maintaining and regularly reviewing for possible parity violations a publicly available consumer complaint log regarding mental health or alcoholism or drug dependency coverage as long as individually identifiable information is excluded.
(1) Ensuring compliance by individual and group health benefit plans;
(2) Detecting possible violations of the law by individual and group health benefit plans;
(3) Accepting, evaluating, and responding to complaints regarding such violations; and
(4) Maintaining and regularly reviewing for possible parity violations a publicly available consumer complaint log regarding mental health or alcoholism or drug dependency coverage as long as individually identifiable information is excluded.
(e) Not later than January 31, 2022, and each year thereafter, the department shall issue a report to the general assembly and provide an educational presentation to the general assembly. The department shall request from the United States department of labor and the United States department of health and human services copies of the NQTL analyses submitted to the departments the previous year in compliance with the federal Consolidated Appropriations Act of 2021 (Pub.L. 116-260) and incorporate these analyses into the report. The report and presentation must: (1) List health plans sold in this state and over which of these plans the department has jurisdiction; (2) Discuss the methodology the department is using to check for compliance with the MHPAEA, and any federal regulations or guidance relating to the compliance and oversight of the MHPAEA, including 45 CFR 146.136 ; (3) Discuss the methodology the department uses to check for compliance with this section and §§ 56-7-2601 and 56-7-2602 ; (4) Identify market conduct examinations and full scope examinations conducted or completed during the preceding twelve-month period and summarize the results of the examinations. Individually identifiable information must be excluded from the reports consistent with federal privacy protections, including, but not limited to, 42 U.S.C. § 290dd-2 and regulations found at 42 CFR § 2.1 through 42 CFR § 2.67 . This discussion must include: (A) The number of full scope examinations and market conduct examinations initiated and completed; (B) The benefit classifications examined by each market conduct examination and full scope examination; (C) The subject matter of each market conduct examination, including quantitative and non-quantitative treatment limitations; (D) A summary of the basis for the final decision rendered in each market conduct examination; and (E) A detailed explanation regarding parity in coverage and rates of reimbursement for mental health services and alcoholism and drug dependency services in compliance with this title and § 71-5-171(b); (5) Detail educational or corrective actions the department of commerce and insurance has taken to ensure health benefit plan compliance with this section, the MHPAEA, 42 U.S.C. § 18031(j) , and §§ 56-7-2601 and 56-7-2602 ; (6) Detail the department's educational approaches relating to informing the public about mental health or alcoholism or drug dependence parity protections under state and federal law; and (7) Describe how the department examines any provider or consumer complaints related to denials or restrictions for possible violations of this section, the MHPAEA, 42 U.S.C. § 18031(j) , and §§ 56-7-2601 and 56-7-2602 , including complaints regarding, but not limited to: (A) Denials of claims for residential treatment or other inpatient treatment on the grounds that such a level of care is not medically necessary; (B) Claims for residential treatment or other inpatient treatment that were approved but for a fewer number of days than requested; (C) Denials of requests, authorizations, pre-authorizations, prior authorizations, concurrent reviews, or claims for residential treatment or other inpatient treatment because the beneficiary had not first attempted outpatient treatment, medication, or a combination of outpatient treatment and medication; (D) Denials of claims for medications such as buprenorphine or naltrexone on the grounds that they are not medically necessary; (E) Step therapy requirements imposed before buprenorphine or naltrexone are approved; (F) Prior authorization requirements imposed on claims for buprenorphine or naltrexone, including those imposed because of safety risks associated with buprenorphine; and (G) Denial of in-network authorization or denials of out-of-network services or claims where there is not an in-network provider within seventy-five (75) miles of the insured patient's home.
(1) List health plans sold in this state and over which of these plans the department has jurisdiction;
(2) Discuss the methodology the department is using to check for compliance with the MHPAEA, and any federal regulations or guidance relating to the compliance and oversight of the MHPAEA, including 45 CFR 146.136 ;
(3) Discuss the methodology the department uses to check for compliance with this section and §§ 56-7-2601 and 56-7-2602 ;
(4) Identify market conduct examinations and full scope examinations conducted or completed during the preceding twelve-month period and summarize the results of the examinations. Individually identifiable information must be excluded from the reports consistent with federal privacy protections, including, but not limited to, 42 U.S.C. § 290dd-2 and regulations found at 42 CFR § 2.1 through 42 CFR § 2.67 . This discussion must include: (A) The number of full scope examinations and market conduct examinations initiated and completed; (B) The benefit classifications examined by each market conduct examination and full scope examination; (C) The subject matter of each market conduct examination, including quantitative and non-quantitative treatment limitations; (D) A summary of the basis for the final decision rendered in each market conduct examination; and (E) A detailed explanation regarding parity in coverage and rates of reimbursement for mental health services and alcoholism and drug dependency services in compliance with this title and § 71-5-171(b);
(A) The number of full scope examinations and market conduct examinations initiated and completed;
(B) The benefit classifications examined by each market conduct examination and full scope examination;
(C) The subject matter of each market conduct examination, including quantitative and non-quantitative treatment limitations;
(D) A summary of the basis for the final decision rendered in each market conduct examination; and
(E) A detailed explanation regarding parity in coverage and rates of reimbursement for mental health services and alcoholism and drug dependency services in compliance with this title and § 71-5-171(b);
(5) Detail educational or corrective actions the department of commerce and insurance has taken to ensure health benefit plan compliance with this section, the MHPAEA, 42 U.S.C. § 18031(j) , and §§ 56-7-2601 and 56-7-2602 ;
(6) Detail the department's educational approaches relating to informing the public about mental health or alcoholism or drug dependence parity protections under state and federal law; and
(7) Describe how the department examines any provider or consumer complaints related to denials or restrictions for possible violations of this section, the MHPAEA, 42 U.S.C. § 18031(j) , and §§ 56-7-2601 and 56-7-2602 , including complaints regarding, but not limited to: (A) Denials of claims for residential treatment or other inpatient treatment on the grounds that such a level of care is not medically necessary; (B) Claims for residential treatment or other inpatient treatment that were approved but for a fewer number of days than requested; (C) Denials of requests, authorizations, pre-authorizations, prior authorizations, concurrent reviews, or claims for residential treatment or other inpatient treatment because the beneficiary had not first attempted outpatient treatment, medication, or a combination of outpatient treatment and medication; (D) Denials of claims for medications such as buprenorphine or naltrexone on the grounds that they are not medically necessary; (E) Step therapy requirements imposed before buprenorphine or naltrexone are approved; (F) Prior authorization requirements imposed on claims for buprenorphine or naltrexone, including those imposed because of safety risks associated with buprenorphine; and (G) Denial of in-network authorization or denials of out-of-network services or claims where there is not an in-network provider within seventy-five (75) miles of the insured patient's home.
(A) Denials of claims for residential treatment or other inpatient treatment on the grounds that such a level of care is not medically necessary;
(B) Claims for residential treatment or other inpatient treatment that were approved but for a fewer number of days than requested;
(C) Denials of requests, authorizations, pre-authorizations, prior authorizations, concurrent reviews, or claims for residential treatment or other inpatient treatment because the beneficiary had not first attempted outpatient treatment, medication, or a combination of outpatient treatment and medication;
(D) Denials of claims for medications such as buprenorphine or naltrexone on the grounds that they are not medically necessary;
(E) Step therapy requirements imposed before buprenorphine or naltrexone are approved;
(F) Prior authorization requirements imposed on claims for buprenorphine or naltrexone, including those imposed because of safety risks associated with buprenorphine; and
(G) Denial of in-network authorization or denials of out-of-network services or claims where there is not an in-network provider within seventy-five (75) miles of the insured patient's home.
(f) The report issued pursuant to subsection (e) must be written in non-technical, readily understandable language and be made available to the public by posting the report on the department's website and by other means as the department finds appropriate. The name and identity of the health insurance carrier must be given confidential treatment, may not be made public by the commissioner or another person, and are not subject to public inspection pursuant to § 10-7-503 .
(g) Benefits under this section shall not be denied for care for confinement provided in a hospital owned or operated by this state that is especially intended for use in the diagnosis, care, and treatment of psychiatric, mental, or nervous disorders.
(h) This section does not apply to accident-only, specified disease, hospital indemnity, medicare supplement, long-term care, or other limited benefit hospital insurance policies.
(i) The commissioner is authorized to promulgate rules to effectuate the purposes of this section. The rules must be promulgated in accordance with the Uniform Administrative Procedures Act, compiled in title 4, chapter 5.
(j) This section does not require the disclosure of information that would violate 42 U.S.C. § 290dd-2 and regulations found at 42 CFR § 2.1 through 42 CFR § 2.67 .
Amended by 2024 Tenn. Acts, ch. 949,s 5, eff. 7/1/2024.
Amended by 2024 Tenn. Acts, ch. 949,s 4, eff. 7/1/2024.
Amended by 2024 Tenn. Acts, ch. 949,s 3, eff. 7/1/2024.
Amended by 2021 Tenn. Acts, ch. 244, s 1, eff. 4/28/2021.
Amended by 2018 Tenn. Acts, ch. 1012, s 1, eff. 1/1/2019.
Acts 1998, ch. 1042, §§ 1, 4.
Tenn. Code Ann. § 56-7-1202 — TN Code / Title 56 / Chapter 7 / Section 56-7-1202
"Uninsured motor vehicle" defined - Coverage of government vehicles
Status: in_force

(a) (1) For the purpose of uninsured motor vehicle coverage, "uninsured motor vehicle" means a motor vehicle whose ownership, maintenance, or use has resulted in the bodily injury, death, or damage to property of an insured, and for which the sum of the limits of liability available to the insured under all valid and collectible insurance policies, bonds, and securities applicable to the bodily injury, death, or damage to property is less than the applicable limits of uninsured motorist coverage provided to the insured under the policy against which the claim is made; and (2) "Uninsured motor vehicle" does not include a motor vehicle: (A) Insured under the liability coverage of the same policy of which the uninsured motor vehicle coverage is a part; (B) Owned by, or furnished for the regular use of, the insured or any resident spouse or resident relative in the same household; (C) Self-insured within the meaning of the Tennessee Financial Responsibility Law, compiled in title 55, chapter 12, or any similar state or federal law; (D) Designed for use mainly off public roads or any off-highway vehicle, as defined in § 55-8-101 , except while the vehicle is operated on public roads pursuant to § 55-8-185 or other law; or (E) While located for use as premises. (b) Notwithstanding any other law, the applicable limits of liability for a governmental unit, political subdivision or agency thereof for claims arising out of the operation of a motor vehicle shall be considered as liability coverage available under a valid and collectible insurance policy. Amended by 2017 Tenn. Acts, ch. 186,s 1, eff. 7/1/2017. Acts 1967, ch. 371, § 2; T.C.A., § 56-1149; Acts 1982, ch. 835, § 2; 1988, ch. 769, § 1; 1999, ch. 196, §§ 2, 3.
(a) (1) For the purpose of uninsured motor vehicle coverage, "uninsured motor vehicle" means a motor vehicle whose ownership, maintenance, or use has resulted in the bodily injury, death, or damage to property of an insured, and for which the sum of the limits of liability available to the insured under all valid and collectible insurance policies, bonds, and securities applicable to the bodily injury, death, or damage to property is less than the applicable limits of uninsured motorist coverage provided to the insured under the policy against which the claim is made; and (2) "Uninsured motor vehicle" does not include a motor vehicle: (A) Insured under the liability coverage of the same policy of which the uninsured motor vehicle coverage is a part; (B) Owned by, or furnished for the regular use of, the insured or any resident spouse or resident relative in the same household; (C) Self-insured within the meaning of the Tennessee Financial Responsibility Law, compiled in title 55, chapter 12, or any similar state or federal law; (D) Designed for use mainly off public roads or any off-highway vehicle, as defined in § 55-8-101 , except while the vehicle is operated on public roads pursuant to § 55-8-185 or other law; or (E) While located for use as premises.
(1) For the purpose of uninsured motor vehicle coverage, "uninsured motor vehicle" means a motor vehicle whose ownership, maintenance, or use has resulted in the bodily injury, death, or damage to property of an insured, and for which the sum of the limits of liability available to the insured under all valid and collectible insurance policies, bonds, and securities applicable to the bodily injury, death, or damage to property is less than the applicable limits of uninsured motorist coverage provided to the insured under the policy against which the claim is made; and
(2) "Uninsured motor vehicle" does not include a motor vehicle: (A) Insured under the liability coverage of the same policy of which the uninsured motor vehicle coverage is a part; (B) Owned by, or furnished for the regular use of, the insured or any resident spouse or resident relative in the same household; (C) Self-insured within the meaning of the Tennessee Financial Responsibility Law, compiled in title 55, chapter 12, or any similar state or federal law; (D) Designed for use mainly off public roads or any off-highway vehicle, as defined in § 55-8-101 , except while the vehicle is operated on public roads pursuant to § 55-8-185 or other law; or (E) While located for use as premises.
(A) Insured under the liability coverage of the same policy of which the uninsured motor vehicle coverage is a part;
(B) Owned by, or furnished for the regular use of, the insured or any resident spouse or resident relative in the same household;
(C) Self-insured within the meaning of the Tennessee Financial Responsibility Law, compiled in title 55, chapter 12, or any similar state or federal law;
(D) Designed for use mainly off public roads or any off-highway vehicle, as defined in § 55-8-101 , except while the vehicle is operated on public roads pursuant to § 55-8-185 or other law; or
(E) While located for use as premises.
(b) Notwithstanding any other law, the applicable limits of liability for a governmental unit, political subdivision or agency thereof for claims arising out of the operation of a motor vehicle shall be considered as liability coverage available under a valid and collectible insurance policy.
Amended by 2017 Tenn. Acts, ch. 186,s 1, eff. 7/1/2017.
Acts 1967, ch. 371, § 2; T.C.A., § 56-1149; Acts 1982, ch. 835, § 2; 1988, ch. 769, § 1; 1999, ch. 196, §§ 2, 3.
Tenn. Code Ann. § 56-6-705 — TN Code / Title 56 / Chapter 6 / Section 56-6-705
Utilization review agents - Minimum standards
Status: in_force

(a) All utilization review agents shall meet the following minimum standards: (1) Notification of a determination by the utilization review agent shall be mailed or otherwise communicated to the provider of record or the enrollee or other appropriate individual within two (2) business days of the receipt of the request for determination and the receipt of all information necessary to complete the review; (2) (A) Any restrictions, preauthorizations, adverse determinations, or final adverse determinations that a utilization review agent places on the preauthorization of health care services shall be based on the medical necessity or appropriateness of those services and shall be based on written clinical criteria; (B) Utilization review agents shall apply written clinical criteria consistently. Written clinical criteria shall: (i) Be based on: (a) Nationally recognized standards including, but not limited to, the standards published by the American College of Cardiology, MCG, Hayes, Inc., or ODG; provided, however, that when multiple standards addressing the same treatment protocol exist, the payer shall have the right to select the standard upon which the written clinical criteria will be based; or (b) Standards developed pursuant to § 50-6-124 ; (ii) Be developed in accordance with the current standards of national accreditation entities or with standards developed pursuant to § 50-6-124 ; (iii) Ensure quality of care and access to needed health care services; (iv) Be evidence-based; and (v) Be evaluated and updated at least annually; (C) A utilization review agent shall make any current preauthorization requirements and restrictions available on its online provider portal. The utilization review agent shall cite to the standards being used and reference the section of the standards relied upon by the utilization review agent. If the utilization review agent is relying upon proprietary references and documentation in developing the clinical criteria, then the utilization review agent shall provide a citation to the proprietary clinical indications being used. Any nonproprietary supporting references and documentation shall be made available to contracted providers if the utilization review agent develops its own clinical criteria; and (D) If a utilization review agent intends to either implement a new preauthorization requirement or restriction, or amend an existing requirement or restriction, the utilization review agent shall provide contracted health care providers with written notice, or other form of notice under the terms of the contract, of the new or amended requirement or restriction no less than sixty (60) days before the requirement or restriction is implemented and shall ensure that such restriction or requirement has been updated on the utilization review agent's web site; (3) Any notification of determination not to certify an admission or service or procedure must include the principal reason for the determination and the procedures to initiate an appeal of the determination; (4) If the utilization review agent requires additional information from an enrollee, a provider, or healthcare facility to make a determination on a request for prior authorization, then, no later than five (5) business days after receipt of the request, the agent shall notify: (A) The enrollee in writing, or through email or respective electronic portals, of the additional information needed to make the determination; and (B) The provider or healthcare facility through email or respective electronic portals of the additional information needed to make the determination; (5) Utilization review agents shall maintain and make available a written description of the appeal procedure by which the enrollee or the provider of record may seek review of a determination by the utilization review agent. The appeal procedure shall provide for the following: (A) On appeal, all determinations not to certify an admission, service, or procedure as being necessary or appropriate shall be made by a physician in the same or a similar general specialty as typically manages the medical condition, procedure or treatment under discussion as mutually deemed appropriate. For mental health and chemical dependency care, the person performing the utilization review in these appeal determinations must be both licensed at the independent practice level and in an appropriate mental health or chemical dependency discipline like that of the provider seeking authorization for the care denied; (B) Utilization review agents shall complete the adjudication of appeals of determinations not to certify admissions, services, and procedures no later than thirty (30) days from the date the appeal is filed and the receipt of all information necessary to complete the appeal; and (C) When an initial determination not to certify a health care service is made prior to or during an ongoing service requiring review, and the attending physician believes that the determination warrants immediate appeal, the attending physician shall have an opportunity to appeal that determination over the telephone on an expedited basis. A representative of a hospital or other health care provider or a representative of the enrollee or covered patient may assist in an appeal. Utilization review agents shall complete the adjudication on an expedited basis. Utilization review agents shall complete the adjudication of expedited appeals within forty-eight (48) hours of the date the appeal is filed and the receipt of all information necessary to complete the appeal. Expedited appeals which do not resolve a difference of opinion may be resubmitted through the standard appeal process; (6) Utilization review agents shall make staff available by toll-free telephone at least forty (40) hours per week during normal business hours; (7) Utilization review agents shall have a telephone system capable of accepting or recording incoming telephone calls during other than normal business hours and shall respond to these calls within two (2) working days; (8) Utilization review agents shall comply with all applicable laws to protect the confidentiality of individual medical records; (9) In the event that nationally recognized standards for a specific treatment protocol do not exist to satisfy the requirements of subdivision (a)(2)(B)(i), a utilization review agent shall ensure that all adverse determinations related to the specific treatment protocol are made by a physician or psychologist. A physician shall possess a valid license to practice medicine and shall be board certified or board eligible, or trained in the similar specialty as the health care provider who typically manages the medical condition or disease, or provides the health care service. A psychologist shall possess a valid license or certificate and shall be board certified or board eligible, or trained in the similar specialty as the health care provider who typically manages the medical condition or disease, or provides the health care service; (10) Utilization review agents shall allow a minimum of twenty-four (24) hours after an emergency admission, service, or procedure for an enrollee or the enrollee's representative to notify the utilization review agent and request certification or continuing treatment for that condition; and (11) (A) For outpatient mental health and chemical dependency care, the patient must register pursuant to the requirements of the policy or contract. After registration, the patient shall be approved for at least twelve (12) visits to a particular provider, except as otherwise provided in this section; (B) Initial utilization review for such outpatient mental health or chemical dependency patients shall be limited to no more than a two (2) page form to be submitted via facsimile or internet and pursuant to state and federal privacy rules, security rules, and any final rules issued pursuant to the Health Insurance Portability and Accountability Act (HIPAA). After November 1, 2005, or sooner if required by HIPAA, the form shall be restricted to a single page. After November 1, 2005, the provider may no longer fax the form but is required to use the internet to submit necessary information if the utilization review agent so requires. In the event that the utilization review agent elects to restrict the submissions to the internet, provisions must be made to fax the information in the event of computer malfunction; (C) After the initial utilization review, additional information or follow-up utilization review for outpatient mental health or chemical dependency patients shall be limited to no more than eighteen percent (18%) of the total number of outpatient mental health and chemical dependency patients' reviews performed by the utilization review agent for the previous calendar year adjusted for the difference of covered lives in this state for the present calendar year, or as otherwise required by the Utilization Review Accreditation Commission (URAC) or the National Committee for Quality Assurance (NCQA). The eighteen-percent limit shall not apply to utilization review applicable to at risk populations, patients seen more than two (2) visits a week and patients for which substance abuse is reported or suspected. Calls from reviews to providers for appointment follow-up calls or for the credentialing process shall also not be subject to the eighteen-percent limit; (D) After utilization review as provided in this subdivision (a)(11), patients shall be authorized for at least twelve (12) additional visits or as otherwise recommended by the treatment plan; (E) Nothing in this part shall be construed to require compliance with the final security and privacy rules of HIPAA prior to the compliance dates set by the secretary of health and human services; and (F) Nothing in this part shall affect the policy or contract benefits nor shall it affect the Mental Health Parity Act, compiled in §§ 56-7-2601 and 56-7-2360 . (b) With the exception of those standards contained in subdivisions (a)(2), (4), (9), and (11), the commissioner shall exempt from the standards of this section a utilization review agent who has received accreditation by URAC or NCQA. Standards contained in subdivisions (a)(2) and (9) do not apply to a TennCare dental benefits management program or a state insurance plan set out in title 8, chapter 27. Subdivision (a)(4) does not apply to the TennCare program or a successor to the program provided for in the Medical Assistance Act of 1968, compiled in title 71, chapter 5, or to the CoverKids Act, compiled in title 71, chapter 3, part 11 or a successor program. Amended by 2022 Tenn. Acts, ch. 664, Secs.s3, s4 eff. 1/1/2023. Amended by 2022 Tenn. Acts, ch. 664, s 2, eff. 1/1/2023. Acts 1992, ch. 812, § 6; 2002, ch. 799, §§ 4, 5; 2007 , ch. 287, §§ 1, 2; 2008 , ch. 812, § 1; 2011 , ch. 243, §§ 1, 2; 2014 , ch. 731, §§ 2 - 4.
(a) All utilization review agents shall meet the following minimum standards: (1) Notification of a determination by the utilization review agent shall be mailed or otherwise communicated to the provider of record or the enrollee or other appropriate individual within two (2) business days of the receipt of the request for determination and the receipt of all information necessary to complete the review; (2) (A) Any restrictions, preauthorizations, adverse determinations, or final adverse determinations that a utilization review agent places on the preauthorization of health care services shall be based on the medical necessity or appropriateness of those services and shall be based on written clinical criteria; (B) Utilization review agents shall apply written clinical criteria consistently. Written clinical criteria shall: (i) Be based on: (a) Nationally recognized standards including, but not limited to, the standards published by the American College of Cardiology, MCG, Hayes, Inc., or ODG; provided, however, that when multiple standards addressing the same treatment protocol exist, the payer shall have the right to select the standard upon which the written clinical criteria will be based; or (b) Standards developed pursuant to § 50-6-124 ; (ii) Be developed in accordance with the current standards of national accreditation entities or with standards developed pursuant to § 50-6-124 ; (iii) Ensure quality of care and access to needed health care services; (iv) Be evidence-based; and (v) Be evaluated and updated at least annually; (C) A utilization review agent shall make any current preauthorization requirements and restrictions available on its online provider portal. The utilization review agent shall cite to the standards being used and reference the section of the standards relied upon by the utilization review agent. If the utilization review agent is relying upon proprietary references and documentation in developing the clinical criteria, then the utilization review agent shall provide a citation to the proprietary clinical indications being used. Any nonproprietary supporting references and documentation shall be made available to contracted providers if the utilization review agent develops its own clinical criteria; and (D) If a utilization review agent intends to either implement a new preauthorization requirement or restriction, or amend an existing requirement or restriction, the utilization review agent shall provide contracted health care providers with written notice, or other form of notice under the terms of the contract, of the new or amended requirement or restriction no less than sixty (60) days before the requirement or restriction is implemented and shall ensure that such restriction or requirement has been updated on the utilization review agent's web site; (3) Any notification of determination not to certify an admission or service or procedure must include the principal reason for the determination and the procedures to initiate an appeal of the determination; (4) If the utilization review agent requires additional information from an enrollee, a provider, or healthcare facility to make a determination on a request for prior authorization, then, no later than five (5) business days after receipt of the request, the agent shall notify: (A) The enrollee in writing, or through email or respective electronic portals, of the additional information needed to make the determination; and (B) The provider or healthcare facility through email or respective electronic portals of the additional information needed to make the determination; (5) Utilization review agents shall maintain and make available a written description of the appeal procedure by which the enrollee or the provider of record may seek review of a determination by the utilization review agent. The appeal procedure shall provide for the following: (A) On appeal, all determinations not to certify an admission, service, or procedure as being necessary or appropriate shall be made by a physician in the same or a similar general specialty as typically manages the medical condition, procedure or treatment under discussion as mutually deemed appropriate. For mental health and chemical dependency care, the person performing the utilization review in these appeal determinations must be both licensed at the independent practice level and in an appropriate mental health or chemical dependency discipline like that of the provider seeking authorization for the care denied; (B) Utilization review agents shall complete the adjudication of appeals of determinations not to certify admissions, services, and procedures no later than thirty (30) days from the date the appeal is filed and the receipt of all information necessary to complete the appeal; and (C) When an initial determination not to certify a health care service is made prior to or during an ongoing service requiring review, and the attending physician believes that the determination warrants immediate appeal, the attending physician shall have an opportunity to appeal that determination over the telephone on an expedited basis. A representative of a hospital or other health care provider or a representative of the enrollee or covered patient may assist in an appeal. Utilization review agents shall complete the adjudication on an expedited basis. Utilization review agents shall complete the adjudication of expedited appeals within forty-eight (48) hours of the date the appeal is filed and the receipt of all information necessary to complete the appeal. Expedited appeals which do not resolve a difference of opinion may be resubmitted through the standard appeal process; (6) Utilization review agents shall make staff available by toll-free telephone at least forty (40) hours per week during normal business hours; (7) Utilization review agents shall have a telephone system capable of accepting or recording incoming telephone calls during other than normal business hours and shall respond to these calls within two (2) working days; (8) Utilization review agents shall comply with all applicable laws to protect the confidentiality of individual medical records; (9) In the event that nationally recognized standards for a specific treatment protocol do not exist to satisfy the requirements of subdivision (a)(2)(B)(i), a utilization review agent shall ensure that all adverse determinations related to the specific treatment protocol are made by a physician or psychologist. A physician shall possess a valid license to practice medicine and shall be board certified or board eligible, or trained in the similar specialty as the health care provider who typically manages the medical condition or disease, or provides the health care service. A psychologist shall possess a valid license or certificate and shall be board certified or board eligible, or trained in the similar specialty as the health care provider who typically manages the medical condition or disease, or provides the health care service; (10) Utilization review agents shall allow a minimum of twenty-four (24) hours after an emergency admission, service, or procedure for an enrollee or the enrollee's representative to notify the utilization review agent and request certification or continuing treatment for that condition; and (11) (A) For outpatient mental health and chemical dependency care, the patient must register pursuant to the requirements of the policy or contract. After registration, the patient shall be approved for at least twelve (12) visits to a particular provider, except as otherwise provided in this section; (B) Initial utilization review for such outpatient mental health or chemical dependency patients shall be limited to no more than a two (2) page form to be submitted via facsimile or internet and pursuant to state and federal privacy rules, security rules, and any final rules issued pursuant to the Health Insurance Portability and Accountability Act (HIPAA). After November 1, 2005, or sooner if required by HIPAA, the form shall be restricted to a single page. After November 1, 2005, the provider may no longer fax the form but is required to use the internet to submit necessary information if the utilization review agent so requires. In the event that the utilization review agent elects to restrict the submissions to the internet, provisions must be made to fax the information in the event of computer malfunction; (C) After the initial utilization review, additional information or follow-up utilization review for outpatient mental health or chemical dependency patients shall be limited to no more than eighteen percent (18%) of the total number of outpatient mental health and chemical dependency patients' reviews performed by the utilization review agent for the previous calendar year adjusted for the difference of covered lives in this state for the present calendar year, or as otherwise required by the Utilization Review Accreditation Commission (URAC) or the National Committee for Quality Assurance (NCQA). The eighteen-percent limit shall not apply to utilization review applicable to at risk populations, patients seen more than two (2) visits a week and patients for which substance abuse is reported or suspected. Calls from reviews to providers for appointment follow-up calls or for the credentialing process shall also not be subject to the eighteen-percent limit; (D) After utilization review as provided in this subdivision (a)(11), patients shall be authorized for at least twelve (12) additional visits or as otherwise recommended by the treatment plan; (E) Nothing in this part shall be construed to require compliance with the final security and privacy rules of HIPAA prior to the compliance dates set by the secretary of health and human services; and (F) Nothing in this part shall affect the policy or contract benefits nor shall it affect the Mental Health Parity Act, compiled in §§ 56-7-2601 and 56-7-2360 .
(1) Notification of a determination by the utilization review agent shall be mailed or otherwise communicated to the provider of record or the enrollee or other appropriate individual within two (2) business days of the receipt of the request for determination and the receipt of all information necessary to complete the review;
(2) (A) Any restrictions, preauthorizations, adverse determinations, or final adverse determinations that a utilization review agent places on the preauthorization of health care services shall be based on the medical necessity or appropriateness of those services and shall be based on written clinical criteria; (B) Utilization review agents shall apply written clinical criteria consistently. Written clinical criteria shall: (i) Be based on: (a) Nationally recognized standards including, but not limited to, the standards published by the American College of Cardiology, MCG, Hayes, Inc., or ODG; provided, however, that when multiple standards addressing the same treatment protocol exist, the payer shall have the right to select the standard upon which the written clinical criteria will be based; or (b) Standards developed pursuant to § 50-6-124 ; (ii) Be developed in accordance with the current standards of national accreditation entities or with standards developed pursuant to § 50-6-124 ; (iii) Ensure quality of care and access to needed health care services; (iv) Be evidence-based; and (v) Be evaluated and updated at least annually; (C) A utilization review agent shall make any current preauthorization requirements and restrictions available on its online provider portal. The utilization review agent shall cite to the standards being used and reference the section of the standards relied upon by the utilization review agent. If the utilization review agent is relying upon proprietary references and documentation in developing the clinical criteria, then the utilization review agent shall provide a citation to the proprietary clinical indications being used. Any nonproprietary supporting references and documentation shall be made available to contracted providers if the utilization review agent develops its own clinical criteria; and (D) If a utilization review agent intends to either implement a new preauthorization requirement or restriction, or amend an existing requirement or restriction, the utilization review agent shall provide contracted health care providers with written notice, or other form of notice under the terms of the contract, of the new or amended requirement or restriction no less than sixty (60) days before the requirement or restriction is implemented and shall ensure that such restriction or requirement has been updated on the utilization review agent's web site;
(A) Any restrictions, preauthorizations, adverse determinations, or final adverse determinations that a utilization review agent places on the preauthorization of health care services shall be based on the medical necessity or appropriateness of those services and shall be based on written clinical criteria;
(B) Utilization review agents shall apply written clinical criteria consistently. Written clinical criteria shall: (i) Be based on: (a) Nationally recognized standards including, but not limited to, the standards published by the American College of Cardiology, MCG, Hayes, Inc., or ODG; provided, however, that when multiple standards addressing the same treatment protocol exist, the payer shall have the right to select the standard upon which the written clinical criteria will be based; or (b) Standards developed pursuant to § 50-6-124 ; (ii) Be developed in accordance with the current standards of national accreditation entities or with standards developed pursuant to § 50-6-124 ; (iii) Ensure quality of care and access to needed health care services; (iv) Be evidence-based; and (v) Be evaluated and updated at least annually;
(i) Be based on: (a) Nationally recognized standards including, but not limited to, the standards published by the American College of Cardiology, MCG, Hayes, Inc., or ODG; provided, however, that when multiple standards addressing the same treatment protocol exist, the payer shall have the right to select the standard upon which the written clinical criteria will be based; or (b) Standards developed pursuant to § 50-6-124 ;
(a) Nationally recognized standards including, but not limited to, the standards published by the American College of Cardiology, MCG, Hayes, Inc., or ODG; provided, however, that when multiple standards addressing the same treatment protocol exist, the payer shall have the right to select the standard upon which the written clinical criteria will be based; or
(b) Standards developed pursuant to § 50-6-124 ;
(ii) Be developed in accordance with the current standards of national accreditation entities or with standards developed pursuant to § 50-6-124 ;
(iii) Ensure quality of care and access to needed health care services;
(iv) Be evidence-based; and
(v) Be evaluated and updated at least annually;
(C) A utilization review agent shall make any current preauthorization requirements and restrictions available on its online provider portal. The utilization review agent shall cite to the standards being used and reference the section of the standards relied upon by the utilization review agent. If the utilization review agent is relying upon proprietary references and documentation in developing the clinical criteria, then the utilization review agent shall provide a citation to the proprietary clinical indications being used. Any nonproprietary supporting references and documentation shall be made available to contracted providers if the utilization review agent develops its own clinical criteria; and
(D) If a utilization review agent intends to either implement a new preauthorization requirement or restriction, or amend an existing requirement or restriction, the utilization review agent shall provide contracted health care providers with written notice, or other form of notice under the terms of the contract, of the new or amended requirement or restriction no less than sixty (60) days before the requirement or restriction is implemented and shall ensure that such restriction or requirement has been updated on the utilization review agent's web site;
(3) Any notification of determination not to certify an admission or service or procedure must include the principal reason for the determination and the procedures to initiate an appeal of the determination;
(4) If the utilization review agent requires additional information from an enrollee, a provider, or healthcare facility to make a determination on a request for prior authorization, then, no later than five (5) business days after receipt of the request, the agent shall notify: (A) The enrollee in writing, or through email or respective electronic portals, of the additional information needed to make the determination; and (B) The provider or healthcare facility through email or respective electronic portals of the additional information needed to make the determination;
(A) The enrollee in writing, or through email or respective electronic portals, of the additional information needed to make the determination; and
(B) The provider or healthcare facility through email or respective electronic portals of the additional information needed to make the determination;
(5) Utilization review agents shall maintain and make available a written description of the appeal procedure by which the enrollee or the provider of record may seek review of a determination by the utilization review agent. The appeal procedure shall provide for the following: (A) On appeal, all determinations not to certify an admission, service, or procedure as being necessary or appropriate shall be made by a physician in the same or a similar general specialty as typically manages the medical condition, procedure or treatment under discussion as mutually deemed appropriate. For mental health and chemical dependency care, the person performing the utilization review in these appeal determinations must be both licensed at the independent practice level and in an appropriate mental health or chemical dependency discipline like that of the provider seeking authorization for the care denied; (B) Utilization review agents shall complete the adjudication of appeals of determinations not to certify admissions, services, and procedures no later than thirty (30) days from the date the appeal is filed and the receipt of all information necessary to complete the appeal; and (C) When an initial determination not to certify a health care service is made prior to or during an ongoing service requiring review, and the attending physician believes that the determination warrants immediate appeal, the attending physician shall have an opportunity to appeal that determination over the telephone on an expedited basis. A representative of a hospital or other health care provider or a representative of the enrollee or covered patient may assist in an appeal. Utilization review agents shall complete the adjudication on an expedited basis. Utilization review agents shall complete the adjudication of expedited appeals within forty-eight (48) hours of the date the appeal is filed and the receipt of all information necessary to complete the appeal. Expedited appeals which do not resolve a difference of opinion may be resubmitted through the standard appeal process;
(A) On appeal, all determinations not to certify an admission, service, or procedure as being necessary or appropriate shall be made by a physician in the same or a similar general specialty as typically manages the medical condition, procedure or treatment under discussion as mutually deemed appropriate. For mental health and chemical dependency care, the person performing the utilization review in these appeal determinations must be both licensed at the independent practice level and in an appropriate mental health or chemical dependency discipline like that of the provider seeking authorization for the care denied;
(B) Utilization review agents shall complete the adjudication of appeals of determinations not to certify admissions, services, and procedures no later than thirty (30) days from the date the appeal is filed and the receipt of all information necessary to complete the appeal; and
(C) When an initial determination not to certify a health care service is made prior to or during an ongoing service requiring review, and the attending physician believes that the determination warrants immediate appeal, the attending physician shall have an opportunity to appeal that determination over the telephone on an expedited basis. A representative of a hospital or other health care provider or a representative of the enrollee or covered patient may assist in an appeal. Utilization review agents shall complete the adjudication on an expedited basis. Utilization review agents shall complete the adjudication of expedited appeals within forty-eight (48) hours of the date the appeal is filed and the receipt of all information necessary to complete the appeal. Expedited appeals which do not resolve a difference of opinion may be resubmitted through the standard appeal process;
(6) Utilization review agents shall make staff available by toll-free telephone at least forty (40) hours per week during normal business hours;
(7) Utilization review agents shall have a telephone system capable of accepting or recording incoming telephone calls during other than normal business hours and shall respond to these calls within two (2) working days;
(8) Utilization review agents shall comply with all applicable laws to protect the confidentiality of individual medical records;
(9) In the event that nationally recognized standards for a specific treatment protocol do not exist to satisfy the requirements of subdivision (a)(2)(B)(i), a utilization review agent shall ensure that all adverse determinations related to the specific treatment protocol are made by a physician or psychologist. A physician shall possess a valid license to practice medicine and shall be board certified or board eligible, or trained in the similar specialty as the health care provider who typically manages the medical condition or disease, or provides the health care service. A psychologist shall possess a valid license or certificate and shall be board certified or board eligible, or trained in the similar specialty as the health care provider who typically manages the medical condition or disease, or provides the health care service;
(10) Utilization review agents shall allow a minimum of twenty-four (24) hours after an emergency admission, service, or procedure for an enrollee or the enrollee's representative to notify the utilization review agent and request certification or continuing treatment for that condition; and
(11) (A) For outpatient mental health and chemical dependency care, the patient must register pursuant to the requirements of the policy or contract. After registration, the patient shall be approved for at least twelve (12) visits to a particular provider, except as otherwise provided in this section; (B) Initial utilization review for such outpatient mental health or chemical dependency patients shall be limited to no more than a two (2) page form to be submitted via facsimile or internet and pursuant to state and federal privacy rules, security rules, and any final rules issued pursuant to the Health Insurance Portability and Accountability Act (HIPAA). After November 1, 2005, or sooner if required by HIPAA, the form shall be restricted to a single page. After November 1, 2005, the provider may no longer fax the form but is required to use the internet to submit necessary information if the utilization review agent so requires. In the event that the utilization review agent elects to restrict the submissions to the internet, provisions must be made to fax the information in the event of computer malfunction; (C) After the initial utilization review, additional information or follow-up utilization review for outpatient mental health or chemical dependency patients shall be limited to no more than eighteen percent (18%) of the total number of outpatient mental health and chemical dependency patients' reviews performed by the utilization review agent for the previous calendar year adjusted for the difference of covered lives in this state for the present calendar year, or as otherwise required by the Utilization Review Accreditation Commission (URAC) or the National Committee for Quality Assurance (NCQA). The eighteen-percent limit shall not apply to utilization review applicable to at risk populations, patients seen more than two (2) visits a week and patients for which substance abuse is reported or suspected. Calls from reviews to providers for appointment follow-up calls or for the credentialing process shall also not be subject to the eighteen-percent limit; (D) After utilization review as provided in this subdivision (a)(11), patients shall be authorized for at least twelve (12) additional visits or as otherwise recommended by the treatment plan; (E) Nothing in this part shall be construed to require compliance with the final security and privacy rules of HIPAA prior to the compliance dates set by the secretary of health and human services; and (F) Nothing in this part shall affect the policy or contract benefits nor shall it affect the Mental Health Parity Act, compiled in §§ 56-7-2601 and 56-7-2360 .
(A) For outpatient mental health and chemical dependency care, the patient must register pursuant to the requirements of the policy or contract. After registration, the patient shall be approved for at least twelve (12) visits to a particular provider, except as otherwise provided in this section;
(B) Initial utilization review for such outpatient mental health or chemical dependency patients shall be limited to no more than a two (2) page form to be submitted via facsimile or internet and pursuant to state and federal privacy rules, security rules, and any final rules issued pursuant to the Health Insurance Portability and Accountability Act (HIPAA). After November 1, 2005, or sooner if required by HIPAA, the form shall be restricted to a single page. After November 1, 2005, the provider may no longer fax the form but is required to use the internet to submit necessary information if the utilization review agent so requires. In the event that the utilization review agent elects to restrict the submissions to the internet, provisions must be made to fax the information in the event of computer malfunction;
(C) After the initial utilization review, additional information or follow-up utilization review for outpatient mental health or chemical dependency patients shall be limited to no more than eighteen percent (18%) of the total number of outpatient mental health and chemical dependency patients' reviews performed by the utilization review agent for the previous calendar year adjusted for the difference of covered lives in this state for the present calendar year, or as otherwise required by the Utilization Review Accreditation Commission (URAC) or the National Committee for Quality Assurance (NCQA). The eighteen-percent limit shall not apply to utilization review applicable to at risk populations, patients seen more than two (2) visits a week and patients for which substance abuse is reported or suspected. Calls from reviews to providers for appointment follow-up calls or for the credentialing process shall also not be subject to the eighteen-percent limit;
(D) After utilization review as provided in this subdivision (a)(11), patients shall be authorized for at least twelve (12) additional visits or as otherwise recommended by the treatment plan;
(E) Nothing in this part shall be construed to require compliance with the final security and privacy rules of HIPAA prior to the compliance dates set by the secretary of health and human services; and
(F) Nothing in this part shall affect the policy or contract benefits nor shall it affect the Mental Health Parity Act, compiled in §§ 56-7-2601 and 56-7-2360 .
(b) With the exception of those standards contained in subdivisions (a)(2), (4), (9), and (11), the commissioner shall exempt from the standards of this section a utilization review agent who has received accreditation by URAC or NCQA. Standards contained in subdivisions (a)(2) and (9) do not apply to a TennCare dental benefits management program or a state insurance plan set out in title 8, chapter 27. Subdivision (a)(4) does not apply to the TennCare program or a successor to the program provided for in the Medical Assistance Act of 1968, compiled in title 71, chapter 5, or to the CoverKids Act, compiled in title 71, chapter 3, part 11 or a successor program.
Amended by 2022 Tenn. Acts, ch. 664, Secs.s3, s4 eff. 1/1/2023.
Amended by 2022 Tenn. Acts, ch. 664, s 2, eff. 1/1/2023.
Acts 1992, ch. 812, § 6; 2002, ch. 799, §§ 4, 5; 2007 , ch. 287, §§ 1, 2; 2008 , ch. 812, § 1; 2011 , ch. 243, §§ 1, 2; 2014 , ch. 731, §§ 2 - 4.
Tenn. Code Ann. § 56-3-409 — TN Code / Title 56 / Chapter 3 / Section 56-3-409
Eligible investments
Status: in_force

Any particular investment that the insurance company held on September 1, 1979, or was obligated to accept by a legally enforceable commitment effectuated prior to September 1, 1979, and that the insurance company was legally entitled to hold immediately prior to September 1, 1979, shall be deemed to be an eligible investment. Acts 1979, ch. 305, § 9; T.C.A., § 56-369.
Any particular investment that the insurance company held on September 1, 1979, or was obligated to accept by a legally enforceable commitment effectuated prior to September 1, 1979, and that the insurance company was legally entitled to hold immediately prior to September 1, 1979, shall be deemed to be an eligible investment.
Acts 1979, ch. 305, § 9; T.C.A., § 56-369.
Tenn. Code Ann. § 56-11-205 — TN Code / Title 56 / Chapter 11 / Section 56-11-205
Submission of ORSA summary report
Status: in_force

(a) Upon the commissioner's request, and no more than once each year, an insurer or health maintenance organization shall submit to the commissioner an ORSA Summary Report or any combination of reports that together contain the information described in the ORSA Guidance Manual, applicable to the insurer, health maintenance organization or the insurance group of which it is a member. Notwithstanding any request from the commissioner, if the insurer or health maintenance organization is a member of an insurance group, the insurer or health maintenance organization shall submit the report or reports required by this subsection (a) if the commissioner is the lead state commissioner of the insurance group as determined by the procedures within the Financial Analysis Handbook adopted by the National Association of Insurance Commissioners. (b) The report or reports shall include a signature of the insurer or insurance group's chief risk officer or other executive having responsibility for the oversight of the insurer's or health maintenance organization's enterprise risk management process attesting to the best of such person's belief and knowledge that the insurer or health maintenance organization applies the enterprise risk management process described in the ORSA Summary Report and that a copy of the report has been provided to the insurer's board of directors or the appropriate committee thereof. (c) An insurer or health maintenance organization may comply with subsection (a) by providing the most recent and substantially similar report or reports provided by the insurer or another member of an insurance group of which the insurer is a member to the commissioner of another state or to a supervisor or regulator of a foreign jurisdiction, if that report provides information that is comparable to the information described in the ORSA Guidance Manual. Any such report in a language other than English must be accompanied by a translation of that report into the English language. Acts 2014, ch. 583, § 26.
(a) Upon the commissioner's request, and no more than once each year, an insurer or health maintenance organization shall submit to the commissioner an ORSA Summary Report or any combination of reports that together contain the information described in the ORSA Guidance Manual, applicable to the insurer, health maintenance organization or the insurance group of which it is a member. Notwithstanding any request from the commissioner, if the insurer or health maintenance organization is a member of an insurance group, the insurer or health maintenance organization shall submit the report or reports required by this subsection (a) if the commissioner is the lead state commissioner of the insurance group as determined by the procedures within the Financial Analysis Handbook adopted by the National Association of Insurance Commissioners.
(b) The report or reports shall include a signature of the insurer or insurance group's chief risk officer or other executive having responsibility for the oversight of the insurer's or health maintenance organization's enterprise risk management process attesting to the best of such person's belief and knowledge that the insurer or health maintenance organization applies the enterprise risk management process described in the ORSA Summary Report and that a copy of the report has been provided to the insurer's board of directors or the appropriate committee thereof.
(c) An insurer or health maintenance organization may comply with subsection (a) by providing the most recent and substantially similar report or reports provided by the insurer or another member of an insurance group of which the insurer is a member to the commissioner of another state or to a supervisor or regulator of a foreign jurisdiction, if that report provides information that is comparable to the information described in the ORSA Guidance Manual. Any such report in a language other than English must be accompanied by a translation of that report into the English language.
Acts 2014, ch. 583, § 26.
Tenn. Code Ann. § 56-2-122 — TN Code / Title 56 / Chapter 2 / Section 56-2-122
Nonprofit health maintenance organization as subsidiary of certain hospital corporations
Status: in_force

A nonprofit health maintenance organization that, with the approval of the commissioner, was created prior to January 1, 1981, by a corporation operated pursuant to chapter 28 or chapter 29 of this title may be treated by the corporation as a subsidiary solely for the purpose of determining the status of the nonprofit health maintenance organization as an admitted asset; provided, that the corporation otherwise has a net worth at least equal to the capital and surplus requirements for an insurance company under §§ 56-2-114(a) and 56-2-115 . Acts 1997 , ch. 65, § 1.
A nonprofit health maintenance organization that, with the approval of the commissioner, was created prior to January 1, 1981, by a corporation operated pursuant to chapter 28 or chapter 29 of this title may be treated by the corporation as a subsidiary solely for the purpose of determining the status of the nonprofit health maintenance organization as an admitted asset; provided, that the corporation otherwise has a net worth at least equal to the capital and surplus requirements for an insurance company under §§ 56-2-114(a) and 56-2-115 .
Acts 1997 , ch. 65, § 1.