Source: http://coveragerights.org/tennessee/
Timestamp: 2019-04-22 14:23:25+00:00

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How do I request a first level appeal?
Request an expedited internal appeal, if applicable. If you are requesting urgent care involving an admission, availability of care, continued stay, or health care service in which you have received emergency services but have not been discharged from the facility, you can request an expedited internal review. Your insurer must provide you with information regarding how to submit the request and any required documentation you will need to submit with the request. You can request an expedited appeal over the phone, in writing, or by email to your health insurer.
How do I request a second level appeal?
If your insurer denies your claim after the first level internal appeal, you can request a second level of internal appeals. This second level internal appeal is entirely optional.
Ask questions of the review panel.
The first level appeal should take a maximum of 30 days if you have not yet received the requested service or treatment and a maximum of 60 days if you have received the service or treatment but are waiting for reimbursement. The second level internal appeal should take a maximum of five business days following the review meeting.
If you request an expedited internal appeal, your health insurer should send you a decision within 72 hours of receiving the request.
Your insurer did not send you a decision on your internal appeal within the required deadlines.
You can also request an expedited external review if your situation is urgent and waiting would jeopardize your life or ability to function. If your situation is urgent, you can request an expedited external review simultaneously with your request for a first level appeal.
You should submit your request for an external review to your health insurer within six months from when your insurer sent you its final decision. Your health insurer must provide you with instructions on how to submit your request. You should submit any new information that you did not previously provide to your health insurer with your request.
Once you submit your request for an external review, your health insurer will then send your request to an external review organization for review. Your health insurer will also send you a notice that an external review organization has been assigned to your case and instructions on how and where to send additional information.
The external review process should take no more than 40 days after the external review organization receives your request. If you requested an expedited external review, the process should take no longer than 72 hours after your request is received by the external review organization.
If you are a Tennessee resident and your insurer still denies your claim after the external review process, you can file a complaint with the Tennessee Department of Commerce and Insurance, Division of Insurance (“Division”).
The Division will forward a copy of your complaint to your health insurer, who has two weeks to respond. The Division will review the insurer’s response. If the Division determines that your insurer violated your insurance policy, the Division will require your insurer to comply. The complaint process time varies, but typically takes one month to complete.
You can contact the Tennessee Department of Commerce and Insurance at (615) 741-2241. The Department is open from 8:00 a.m. to 4:30 p.m., Monday through Friday.
 Appealing a Health Plan Decision, Healthcare.gov, https://www.healthcare.gov/appeal-insurance-company-decision/appeals/ (last visited Nov. 26, 2016).
 Tenn. Code Ann. § 56-61-109(b) (2016).
 Tenn. Code Ann. § 56-61-109(e) (2016).
 Tenn. Code Ann. § 56-61-108 (2016).
 Tenn. Code Ann. § 56-61-107(e)(2) (2016).
 Tenn. Code Ann. § 56-61-108(b)(2) (2016).
 Tenn. Code Ann. § 56-61-109(f)(1) (2016).
 Tenn. Code Ann. § 56-61-115 (2016).
 Tenn. Code Ann. § 56-61-117 (2016).
 Appealing a Health Plan Decision: Internal Appeals, Healthchare.gov, https://www.healthcare.gov/appeal-insurance-company-decision/internal-appeals/ (last visited Nov. 26, 2016).
 Tenn. Code Ann. § 56-61-116(a) (2016).
 Tenn. Code Ann. § 56-61-113 (2016).
 Tenn. Code Ann. § 56-61-116 (2016).
 Tenn. Code Ann. § 56-61-116(m) (2016).
 Tenn. Code Ann. § 56-61-117(f)(1)(B) (2016).
 Complaint Form, Tennessee Department of Commerce & Insurance, https://sbs-tn.naic.org/Lion-Web/servlet/org.naic.sbs.ext.onlineComplaint.OnlineComplaintCtrl?spanishVersion=N (last visited Nov. 26, 2016).
 Complaint to Federal Government Agency: Patient, Legal Action Center, https://lac.org/wp-content/uploads/2016/04/10-Patient-Federal-Complaint.docx (last visited Oct. 17, 2016).

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