reglab/housing_qa huggingface dataset:
TN Code § 56-60-107 (2021)
2021 Tennessee Code|Title 56 - Insurance|Chapter 60 - Preferred Provider Organization Transparency Act|§ 56-60-107. Requirements for Granting a Third Party Access to the Contracting Entity's Provider Network — Refusal to Accept Contractual Discount

  No contracting entity shall grant a third party access to the contracting entity's provider network contract by lease, rent or by any other means unless the third party accessing the provider network contract is:  A payer of claims or a third party administrator or other entity that administers or processes claims on behalf of the payer;   A preferred provider organization or preferred provider network including a physician organization or physician hospital organization; or   An entity engaged in the electronic claims transport between the contracting entity and the payer if the entity does not provide access to the provider's services and contractual discounts to any other third party.      A provider may refuse the discount taken on the remittance advice (RA) or explanation of payment (EOP) if the discount is taken without a contractual basis or if the provider cannot obtain information relative to the discount because of a violation of § 56-60-105(b)(2) or § 56-60-106(c). The provider shall notify in writing the contracting entity or third party of the provider's refusal to accept the contractual discount.   The provider may require payment of the charge with no discount applied unless the contracting entity or third party within thirty (30) calendar days of receipt of notice of the apparent violation of the requirements of this section:  Notifies the provider that the apparent violation resulted from an administrative oversight or other unintentional error and advises the provider of steps taken to remedy and avoid recurrence of the error; and   Submits to the provider a corrected RA or EOP with documentation demonstrating eligibility for any discount applied.
TN Code § 56-60-108 (2021)
2021 Tennessee Code|Title 56 - Insurance|Chapter 60 - Preferred Provider Organization Transparency Act|§ 56-60-108. Enforcement — Rules

  The department shall enforce this chapter.   The department is authorized to promulgate rules to effectuate this chapter in accordance with the Uniform Administrative Procedures Act, compiled in title 4, chapter 5. The initial rules promulgated by the department may be designated as emergency rules if the department finds that it cannot implement the rules by January 1, 2010, exercising the rulemaking procedures for the promulgation of permanent rules and if the department complies with § 4-5-208.
TN Code § 56-60-109 (2021)
2021 Tennessee Code|Title 56 - Insurance|Chapter 60 - Preferred Provider Organization Transparency Act|§ 56-60-109. Unfair Insurance Practice — Complaints for Violations

  It is an unfair insurance practice for the purposes of the Tennessee Unfair Trade Practices and Unfair Claims Settlement Act of 2009, compiled in chapter 8, part 1 of this title, to knowingly access a provider's services or exercise a provider's contractual discounts pursuant to a provider network contract if the access or exercise is not pursuant to a contractual relationship with the provider or with a contracting entity or third party who has a contractual relationship with the provider as specified in this chapter.    To effectuate the purposes of this section, the department shall develop a complaint form for providers or others to submit alleging violations of this chapter.   Information provided in good faith to the department shall not make the provider or other individual or entity providing the information liable for civil damages as a result of providing the information.
TN Code § 56-61-101 (2021)
2021 Tennessee Code|Title 56 - Insurance|Chapter 61 - Tennessee Health Carrier Grievance and External Review Procedure Act|§ 56-61-101. Short Title — Purpose

  This chapter shall be known and may be cited as the “Tennessee Health Carrier Grievance and External Review Procedure Act.”   The purpose of this chapter is to provide standards for the establishment and maintenance of procedures by health carriers to assure that covered persons and healthcare providers have the opportunity for the appropriate resolution of grievances, as defined in this chapter.
TN Code § 56-61-103 (2021)
2021 Tennessee Code|Title 56 - Insurance|Chapter 61 - Tennessee Health Carrier Grievance and External Review Procedure Act|§ 56-61-103. Applicability and Scope

  Except as otherwise specified, this chapter shall apply to all health carriers.   This chapter shall not apply to a policy or certificate that provides:  Coverage only for a specified disease, specified accident or accident-only coverage, credit, dental, disability income, hospital indemnity, long-term care insurance, as defined by § 56-42-103, vision care or any other limited supplemental benefit or to a medicare supplement policy of insurance as defined by the commissioner;   Coverage under a plan through medicare, medicaid or the federal employees health benefits program (FEHB);   Any coverage issued under 10 U.S.C. § 1072 and any coverage issued as supplement to that coverage;   Any coverage issued as supplemental to liability insurance; workers' compensation or similar insurance; automobile medical-payment insurance or any insurance under which benefits are payable without regard to fault; whether written on a group blanket or individual basis; or   Any plan exempt from regulation under this title due to the Employee Retirement Income Security Act of 1974 (ERISA) (29 U.S.C. § 1144).
TN Code § 56-61-104 (2021)
2021 Tennessee Code|Title 56 - Insurance|Chapter 61 - Tennessee Health Carrier Grievance and External Review Procedure Act|§ 56-61-104. No Limitations or Restrictions on Denying Coverage of Services Not Medically Necessary

 Nothing in this chapter shall limit or restrict the health carrier from denying coverage on the grounds that the services are determined not to be medically necessary.
TN Code § 56-61-105 (2021)
2021 Tennessee Code|Title 56 - Insurance|Chapter 61 - Tennessee Health Carrier Grievance and External Review Procedure Act|§ 56-61-105. Maintenance of Register of Written Records to Document Grievances

  A health carrier shall maintain written records to document all grievances received during a calendar year. The register shall be maintained in a manner that is reasonably clear and accessible to the commissioner.   A request for a first level review of a grievance involving an adverse determination shall be processed in compliance with § 56-61-107 and is required to be included in the health carrier's register.   A request for a second level review of a grievance involving an adverse determination that may be conducted pursuant to § 56-61-108 shall be included in the health carrier's register.   For each grievance, the register shall contain, at a minimum, the following information:  A general description of the reason for the grievance;   The date the grievance was received;   The date of each review or, if applicable, review meeting;   The resolution at each level of the grievance, if applicable;   The date of resolution at each level, if applicable; and   The name of the aggrieved person for whom the grievance was filed.      A health carrier shall retain the register compiled for a calendar year for the shorter of five (5) years or until the commissioner has adopted a final report of an examination that contains a review of the register for such calendar year.    A health carrier shall submit to the commissioner, at least annually, a report in the format specified by the commissioner.   The report shall include for each type of health benefit plan offered by the health carrier:   The number of covered lives that fall under this chapter's protections;   The total number of grievances;   The number of grievances for which a covered person and healthcare provider requested a second level voluntary grievance review pursuant to § 56-61-108;   The number of grievances resolved at each level, if applicable, and their resolution; and   A synopsis of actions being taken to correct problems identified.
TN Code § 56-61-106 (2021)
2021 Tennessee Code|Title 56 - Insurance|Chapter 61 - Tennessee Health Carrier Grievance and External Review Procedure Act|§ 56-61-106. Written Procedures for Grievances

  Except as specified in § 56-61-109, a health carrier shall use written procedures for receiving and resolving grievances from aggrieved persons, as provided in §§ 56-61-107 and 56-61-108, unless otherwise provided by this chapter.   A health carrier shall file with the commissioner a copy of the procedures required under subsection (a), including all forms used to process requests made pursuant to §§ 56-61-107 and 56-61-108. Any subsequent material modifications to the documents also shall be filed.   A description of the grievance procedures required under this section shall be set forth in or attached to the membership booklet, provider manual, and health carrier's web site. The health carrier may include a description of the grievance procedures in the policy, certificate, outline of coverage or other evidence of coverage provided to aggrieved persons.
TN Code § 56-61-110 (2021)
2021 Tennessee Code|Title 56 - Insurance|Chapter 61 - Tennessee Health Carrier Grievance and External Review Procedure Act|§ 56-61-110. Rules and Regulations

 The commissioner may, after notice and hearing, promulgate reasonable rules and regulations to carry out this chapter. Such rules and regulations shall be subject to review in accordance with the Uniform Administrative Procedures Act, compiled in title 4, chapter 5.
TN Code § 56-61-111 (2021)
2021 Tennessee Code|Title 56 - Insurance|Chapter 61 - Tennessee Health Carrier Grievance and External Review Procedure Act|§ 56-61-111. Penalties for Violations

 A person that violates this chapter shall be subject to the penalties set forth in § 56-2-305.
TN Code § 56-61-112 (2021)
2021 Tennessee Code|Title 56 - Insurance|Chapter 61 - Tennessee Health Carrier Grievance and External Review Procedure Act|§ 56-61-112. Elections for Conducting External Review Program

  For purposes of this section, “approved entity” means:  The utilization review accreditation commission (URAC); or   Other nationally recognized private accrediting entity employing standards for the accreditation of external review programs that the commissioner deems are substantially equivalent to the standards for conducting an external review pursuant to §§ 56-61-113 — 56-61-118.     A health carrier may elect, in writing to the commissioner, to conduct its external review program in accordance with:  Sections 56-61-113  — 56-61-118, or   The external review program of an approved entity; provided, that the health carrier receives and maintains accreditation from the approved entity. Sections 56-61-120 and 56-61-121 shall not apply to a health carrier that receives and maintains accreditation from the approved entity.     The commissioner may evaluate the external review procedures of an approved entity. If after a hearing is conducted in accordance with the Uniform Administrative Procedures Act, compiled in title 4, chapter 5, the commissioner finds that an approved entity has amended its external review procedures to the extent that such procedures are no longer consistent with the purposes of this chapter, the commissioner shall issue a written order specifying in what respects those procedures are inconsistent.   A health carrier that has elected to conduct its external review program in accordance with the standards of an approved entity, that is the subject of the commissioner's order issued pursuant to subsection (c), shall have sixty (60) days from the effective date of the commissioner's order to:  Elect, in writing, to utilize another external review program under subsection (b); or   Demonstrate to the commissioner's satisfaction that the approved entity has subsequently amended its procedures so that such procedures are consistent with the purposes of this chapter.
TN Code § 56-61-114 (2021)
2021 Tennessee Code|Title 56 - Insurance|Chapter 61 - Tennessee Health Carrier Grievance and External Review Procedure Act|§ 56-61-114. Request for External Review

  Except for a request for an expedited external review as set forth in § 56-61-117 or § 56-61-118(n), all requests for external review shall be made in writing to the health carrier.   Unless otherwise set forth by this chapter, an aggrieved person may file a request for external review after the receipt of a final adverse determination.
TN Code § 56-61-115 (2021)
2021 Tennessee Code|Title 56 - Insurance|Chapter 61 - Tennessee Health Carrier Grievance and External Review Procedure Act|§ 56-61-115. Exhaustion of Internal Grievance Process

  Except as provided in subsection (b), a request for an external review pursuant to § 56-61-116 or § 56-61-118 shall not be made until the aggrieved person has exhausted the health carrier's internal grievance process as set forth in this chapter.  An aggrieved person shall be considered to have exhausted the health carrier's internal grievance process for purposes of this section, if the aggrieved person:  Has filed a grievance involving an adverse determination pursuant to § 56-61-107; and   Has not received a written decision on the grievance from the health carrier within thirty (30) days for prospective review determinations and sixty (60) days for retrospective review determinations following the date that the aggrieved person filed the grievance with the health carrier unless the aggrieved person requested or agreed to a delay.     Notwithstanding subdivision (a)(1)(B), an aggrieved person may not file a request for an external review of an adverse determination involving a retrospective review determination until the covered person has exhausted the health carrier's internal grievance process.     A request for an external review of an adverse determination may be filed before the covered person has exhausted the health carrier's internal grievance procedures, as set forth in § 56-61-107, whenever the health carrier agrees to waive the exhaustion requirement.   If the requirement to exhaust the health carrier's internal grievance procedures is waived pursuant to subsection (b), the aggrieved person may file a request in writing for a standard external review as set forth in § 56-61-116 or § 56-61-118.
TN Code § 56-61-119 (2021)
2021 Tennessee Code|Title 56 - Insurance|Chapter 61 - Tennessee Health Carrier Grievance and External Review Procedure Act|§ 56-61-119. Binding Nature of External Review Decisions

  An external review decision is binding on the health carrier except to the extent that the health carrier has other remedies available under applicable federal or state law.   An external review decision is binding on the covered person except to the extent that the covered person has other remedies available under applicable federal or state law.   An external review decision is binding on the healthcare provider except to the extent that the healthcare provider has other remedies available under applicable federal or state law.   An aggrieved person may not file a subsequent request for external review involving the same adverse determination or final adverse determination for which the covered person has already received an external review decision pursuant to this chapter.
TN Code § 56-61-120 (2021)
2021 Tennessee Code|Title 56 - Insurance|Chapter 61 - Tennessee Health Carrier Grievance and External Review Procedure Act|§ 56-61-120. Approval of External Review Organizations

  The commissioner shall approve external review organizations eligible to conduct external reviews under this chapter.   In order to be eligible for approval by the commissioner to conduct external reviews under this chapter, an external review organization:  Except as otherwise provided in this section, shall be accredited by a nationally recognized private accrediting entity that the commissioner has determined has external review organization accreditation standards that are equivalent to or exceed the minimum qualifications for external review organizations established under § 56-61-121; and   Shall submit an application for approval in accordance with subsection (d).     The commissioner shall develop an application form for initially approving and for reapproving external review organizations to conduct external reviews.   Any external review organization wishing to be approved to conduct external reviews under this chapter shall submit the application form and include with the form all documentation and information necessary for the commissioner to determine if the external review organization satisfies the minimum qualifications established under § 56-61-121.   Subject to subsection (b), an external review organization is eligible for approval under this section only if it is accredited by a nationally recognized private accrediting entity that the commissioner has determined has external review organization accreditation standards that are equivalent to or exceed the minimum qualifications for external review organizations under § 56-61-121.   The commissioner may approve external review organizations that are not accredited by a nationally recognized private accrediting entity if there are no acceptable nationally recognized private accrediting entities providing external review organization accreditation.   The commissioner may charge an application fee that external review organizations shall submit to the commissioner with an application for approval and reapproval.   An approval is effective for two (2) years, unless the commissioner determines before its expiration that the external review organization is not satisfying the minimum qualifications established under § 56-61-121. Whenever the commissioner determines that an external review organization has lost its accreditation or no longer satisfies the minimum requirements established under § 56-61-121, the commissioner shall terminate the approval of the external review organization and remove the external review organization from the list of external review organizations approved to conduct external reviews under this chapter that is maintained by the commissioner pursuant to subsection (i).   The commissioner shall maintain and periodically update a list of approved external review organizations.   The commissioner may promulgate rules and regulations to carry out  this section.
TN Code § 56-61-122 (2021)
2021 Tennessee Code|Title 56 - Insurance|Chapter 61 - Tennessee Health Carrier Grievance and External Review Procedure Act|§ 56-61-122. Hold Harmless for External Review Organizations

 No external review organization or clinical reviewer working on behalf of an external review organization or an employee, agent or contractor of an external review organization shall be liable in damages to any person for any opinions rendered or acts or omissions performed within the scope of the organization's or person's duties under the law during or upon completion of an external review conducted pursuant to this chapter, unless the opinion was rendered or act or omission performed in bad faith or involved gross negligence.
TN Code § 56-61-123 (2021)
2021 Tennessee Code|Title 56 - Insurance|Chapter 61 - Tennessee Health Carrier Grievance and External Review Procedure Act|§ 56-61-123. External Review Reporting Requirements

  An external review organization conducting an external review pursuant to this chapter shall maintain written records in the aggregate by state and by health carrier on all requests for external review for which it conducted an external review during a calendar year and, upon request, submit a report to the commissioner, as required under subdivision (a)(2).  Each external review organization required to maintain written records on all requests for external review for which it conducted an external review shall submit to the commissioner, upon request, a report in the format specified by the commissioner.   The report shall include in the aggregate by state, and for each health carrier:  The total number of requests for external review;   The number of requests for external review resolved and, of those resolved, the number resolved upholding the adverse determination or final adverse determination and the number resolved reversing the adverse determination or final adverse determination;   The average length of time for resolution;   A summary of the types of coverages or cases for which an external review was sought, as provided in the format required by the commissioner;   The number of external reviews pursuant to § 56-61-116 that were terminated as the result of a reversal by the health carrier of its adverse determination or final adverse determination after the receipt of additional information from the aggrieved person; and   Any other information that the commissioner may request or require.     The external review organization shall retain the written records required pursuant to this subsection (a) for at least three (3) years.     Each health carrier shall maintain written records in the aggregate, by state and for each type of health benefit plan offered by the health carrier on all requests for external review that the health carrier receives notice of from the commissioner pursuant to this chapter.  Each health carrier required to maintain written records on all requests for external review pursuant to this subsection (b) shall submit to the commissioner, upon request, a report in the format specified by the commissioner.   The report shall include in the aggregate, by state, and by type of health benefit plan:  The total number of requests for external review;   From the total number of requests for external review reported under subdivision (b)(2)(A), the number of requests determined eligible for a full external review; and   Any other information that the commissioner may request or require.     The health carrier shall retain the written records required pursuant to this subsection (b) for at least three (3) years.
TN Code § 56-61-124 (2021)
2021 Tennessee Code|Title 56 - Insurance|Chapter 61 - Tennessee Health Carrier Grievance and External Review Procedure Act|§ 56-61-124. Funding of External Review

 The health carrier against which a request for a standard external review or an expedited external review is filed shall pay the cost of the external review organization for conducting the external review.
TN Code § 56-61-125 (2021)
2021 Tennessee Code|Title 56 - Insurance|Chapter 61 - Tennessee Health Carrier Grievance and External Review Procedure Act|§ 56-61-125. Disclosure Requirements

  Each health carrier shall include a description of the external review procedures in or attached to the membership booklet, provider manual, and health carrier's web site. The health carrier may include a description of the external review procedures in the policy, certificate, outline of coverage, or other evidence of coverage provided to covered persons and providers.   The disclosure required by subsection (a) shall be in a format prescribed by the commissioner.   The description required under subsection (a) shall include a statement that informs the aggrieved person of the aggrieved person's right to file a request for an external review of an adverse determination or final adverse determination with the carrier. The statement shall include the telephone number and address of the commissioner.   In addition to subsection (b), the statement shall inform the covered person that, when filing a request for an external review, the covered person will be required to authorize the release of any medical records of the covered person that may be required to be reviewed for the purpose of reaching a decision on the external review.