State RegulationsTN specificDifficulty 2/5
A Tennessee health plan member receives an adverse determination from her carrier and has completed the carrier's internal grievance process without success. What does the state's external review framework provide her?
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Answer & full 3-part explanation (select an option above, or peek)
Why B is correct
The Tennessee Health Carrier Grievance and External Review Procedure Act, through its external review provisions at T.C.A. § 56-61-113 and 56-61-116, provides a process for independent external review of a health carrier's adverse determinations. A member who has gone through the carrier's internal grievance process may invoke that state framework rather than being left with only the carrier's own decision, and the Tennessee Department of Commerce & Insurance oversees the procedure.
Why the other options are wrong
- A) External review does not automatically reverse the carrier's determination; it submits the dispute to independent review.
- C) A premium refund is not the external review remedy; the framework concerns review of the adverse determination itself.
- D) The state framework provides an administrative external review route; it does not condition review on first filing a lawsuit.
Memory hook
Internal first, then independent eyes.