External review in Tennessee: a state process you file with the carrier

Who can file, and where the request goes

Chapter 61 defines an 'aggrieved person' as a healthcare provider, a covered person, or an authorized representative (Tenn. Code Ann. § 56-61-102(2)). A Tennessee practice can therefore work the internal grievance and then the external review under its own name, without first assembling representative paperwork for the patient. Few states put the provider in the statute this directly.

The second Tennessee-specific mechanic is where the paper goes. Every request for external review is made in writing to the health carrier (§ 56-61-114(a)), and expedited requests go there too (§ 56-61-117(a)). Tennessee publishes no state application form and no state filing portal. The carrier owes you its written process description and the medical-records release form it wants used (§ 56-61-125).

• Reviewable grounds: medical necessity, level of care, setting, effectiveness, and eligibility-based nonpayment.
• The written request goes to the carrier — not to TDCI, and not on a state form.
• A healthcare provider files as an 'aggrieved person' in its own right, on the same clock as the patient.
• Chapter 61 does not reach ERISA self-funded plans, Medicare, Medicaid/TennCare, FEHB, or limited and supplemental products (§ 56-61-103(b)).

Six months in the statute, 180 days on the Department's sheet

Section 56-61-116(a) gives an aggrieved person six months after receipt of an adverse determination or final adverse determination to request external review. That is one of the longer windows in the country, and it is the same window for a provider filing on its own behalf — Tennessee sets no separate, shorter provider clock. TDCI's official external-review disclosure document states the deadline as 180 days from receiving a final determination. The two spans do not always land on the same date.

The internal grievance comes first (§ 56-61-115). If the carrier issues no written decision within 30 days on a prospective request or 60 days on a retrospective one, exhaustion is deemed satisfied and the case can move (§ 56-61-115(a)(1)(B)). Retrospective denials — the post-service claim a billing office usually works — have no other route around exhaustion.

How to file

1. 1

   Take the internal grievance to a written decision

   Work the carrier's grievance first. If no written decision arrives within 30 days on a prospective request or 60 days on a retrospective one, exhaustion is deemed met under § 56-61-115(a)(1)(B).

2. 2

   Write to the carrier, not to the state

   Section 56-61-114(a) requires the request in writing to the health carrier. Ask at the same time for the process description and the medical-records release form the carrier owes you under § 56-61-125.

3. 3

   File in the practice's name if that is simpler

   A healthcare provider is an 'aggrieved person' under § 56-61-102(2)(A) and can file directly, on the same window as the patient.

4. 4

   Get the clinical material in within six business days

   Once the case clears eligibility, the filer has six business days to send additional information to the review organization. The carrier has six business days to send its file — and if it misses, the reviewer may terminate the review and reverse the denial outright.

5. 5

   If the carrier calls it ineligible, go to the Commissioner

   An eligibility determination is appealable. The Commissioner can overrule the carrier and order the case into external review (§ 56-61-116(e)-(f); § 56-61-117(b)(2) for expedited).

The carrier assigns the reviewer — and the clocks that follow

Tennessee is a carrier-assignment state, which is the sharp contrast with programs where a regulator rotates cases. Section 56-61-116(q) requires each health carrier to hold contracts with at least two external review organizations and lets the carrier assign the case; the statute also permits the carrier to give the filer the opportunity to select among those contracted organizations. Random assignment is a contingency, available if the Commissioner is directed by HHS to impose it, not the ordinary rule. TDCI's hold is on the front end — approving and qualifying the organizations under §§ 56-61-120 and -121 — and on eligibility overrides. Individual clinical reviewers cannot be handpicked by the carrier, the covered person, or the representative. A carrier may also elect, in writing to the Commissioner, to run its whole external-review program under URAC's or an equivalent accreditor's program instead of the statutory one (§ 56-61-112).

One drafting detail is useful when a case drags: the decision notice must state the date the review organization received the assignment from the carrier (§ 56-61-116(o)(2)), which shows how long the file sat before review began. On outcomes, Chapter 61 sets up no standing public report — § 56-61-123 has review organizations and carriers send aggregate data to the Commissioner upon request — so there is no published Tennessee overturn rate we can point you to.

• Eligibility review: 10 business days for the carrier, then 3 business days to notify.
• Six business days for the filer to add material; six business days for the carrier to send its file, with termination and reversal available if it misses.
• Standard decision: within 40 days of the request under § 56-61-116(m). TDCI's disclosure document prints 45 days. The reviewer notifies the carrier within 2 calendar days and the carrier notifies you within 3.
• Expedited: no more than 72 hours, with written confirmation within 48 hours if the first notice was oral (§ 56-61-117(f)). Not available at all for retrospective, post-service denials (§ 56-61-117(g)).
• Cost: none to the patient or the provider — the carrier pays the review organization for standard and expedited reviews alike (§ 56-61-124).
• On reversal: coverage must be approved immediately, and where the dispute involves paying the provider, the carrier pays within 10 business days (§ 56-61-116(n), (p)).

What Chapter 61 will not review

Tennessee's definition of 'retrospective review' expressly excludes review of a claim limited to the veracity of documentation or the accuracy of coding (§ 56-61-102(31)). A pure bundling or coding denial is therefore not an adverse determination that can be driven into external review here. Most such claims still carry a medical-necessity, level-of-care, or setting question underneath the coding dispute, and that question is reviewable. Build the appeal on the clinical determination and keep the coding argument on the carrier's own claim-dispute track.

Eligibility is the other place Tennessee diverges. When the carrier decides a request is not eligible for external review, that call goes to the Commissioner, who can overrule it and order the case reviewed (§ 56-61-116(e)-(f)). Separately, complaints go to TDCI Consumer Insurance Services, which publishes an online complaint form and a complaint form specifically for provider use; mail reaches the division at 500 James Robertson Parkway, 10th Floor, Nashville, TN 37243, and the help line is 615-741-2218 or 1-800-342-4029. Questions about the review organizations themselves go to the Policy Analysis Section at [email protected].

TennCare runs a separate provider-only track

TennCare and CoverKids sit outside Chapter 61 entirely. A provider who believes a TennCare managed care contractor wrongly denied claims uses the independent review process under Tenn. Code Ann. § 56-32-126(b)(2), administered by TDCI's TennCare Oversight Division. The differences from commercial external review are large: 365 days from the first denial to file, a decision that binds subject to court review, and 60 days of silence from the contractor counting as a denial. The fee is $750, effective July 1, 2015, paid by whichever side loses — the contractor pays if the provider prevails, the provider pays if it does not.

For Tennessee providers: the Prior Authorization Fairness Act

2023 Public Chapter 395 added Part 37 to Title 56, Chapter 7 (§§ 56-7-3701 to -3722), and several of its requirements give a practice something concrete to hold a carrier to before a denial ever reaches external review. A denial notice must state the reason, the evidence-based criteria applied, what documentation was missing, and how to appeal (§ 56-7-3703(a)). A prior-authorization denial has to be made by a physician or a professional of the same or similar specialty as the one who requested the service (§ 56-7-3703(b)). Electronic PA appeals go to a same-or-similar-specialty licensed reviewer who was not involved in the original denial, decided within 7 calendar days when non-urgent and 72 hours when urgent (§ 56-7-3704). No one may be compensated as an incentive to deny (§ 56-7-3704(a)(3)). Clinical criteria must be nationally recognized, evidence-based, non-arbitrary, and cited by the review organization (§ 56-7-3707(b)). A claim cannot be denied for lack of prior authorization if the requirement was not in effect on the date of service (§ 56-7-3707(c)), an approved authorization holds for at least six months (§ 56-7-3709), and carriers must review their PA requirements annually with an eye to removing them (§ 56-7-3718).

The provision worth knowing by number is § 56-7-3717: carriers and utilization review organizations must publish de-identified aggregate prior-authorization statistics on their websites by service code — approvals, denials, appeals, overturns, turnaround times, and the top five reasons for denial. That is the carrier's own published record on the exact code you are appealing, and it belongs in the file. Part 37 does not apply to ERISA plans, TennCare contracts, TennCare, or CoverKids (§ 56-7-3720). Tennessee's step-therapy protocol law, with its required exception process, sits separately at § 56-7-3502.

Written criteria, and a specialty match on appeal

Tennessee requires two things of any restriction, preauthorization or adverse determination a utilization review agent imposes. Under Tenn. Code Ann. 56-6-705, it must rest on medical necessity or appropriateness and on written clinical criteria — not on one without the other.

On appeal the standard is a person, not a document. A determination not to certify must be made by a physician in the same or a similar general specialty as typically manages the condition, procedure or treatment: a physician holding a valid license who is board certified, board eligible, or trained in that similar specialty. Notification of a determination is due within two business days of the agent receiving the request together with all information needed to complete the review.