State guide
Tennessee
Pick the kind of plan you have to see who to call first. Tennessee can only help with plans it regulates.
Which plan do you have? Who to call first, by coverage
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Your employer pays claims itself
Tennessee usually cannot help with these plans. Call the Employee Benefits Security Administration.
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Insurance you buy, or an employer plan bought from an insurer
Call Tennessee Department of Commerce and Insurance, Insurance Division (Consumer Insurance Services). See the at-a-glance box.
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Medicaid or children's coverage
Call the number on your notice and ask to appeal, and to keep services going while you appeal. The hearing deadline is under Medicaid in Tennessee.
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Medicare
Tennessee State Health Insurance Assistance Program (TN SHIP) gives free counseling. Or call 1-800-MEDICARE.
The short version for Tennessee
Tennessee runs its own external review process, but unlike most states you send the request to your health insurer, not to the state, and you have six months rather than four. The Department of Commerce and Insurance's Consumer Insurance Services section mediates complaints and can overrule an insurer that says your request is not eligible. State law also sets firm prior authorization deadlines and a step therapy exception that is granted automatically if the insurer does not answer in time.
At a glance: independent review for plans Tennessee regulates
- Main regulator
- Tennessee Department of Commerce and Insurance, Insurance Division (Consumer Insurance Services) · 615-741-2218 or 1-800-342-4029
- Independent review
- A state process (External review)
- Deadline to request it
- Within six months after you receive the notice of the denial (adverse determination or final adverse determination)
- Cost
- No filing fee appears in the state law; the health insurer must pay the cost of the external review organization
- Decision time
- Within 40 days after the external review organization receives the request; fast track: As fast as your condition requires and no more than 72 hours after the request is received
Who regulates health plans
The Department says it can take a complaint only if the insurance policy was written in Tennessee. Complaints involving TennCare, CoverKids or CoverRx go to the TennCare Oversight Division rather than Consumer Insurance Services.
- Tennessee Department of Commerce and Insurance, Insurance Division (Consumer Insurance Services)
Insurance companies and agents for policies written in Tennessee, including individual and fully insured employer health plans. Complaints about TennCare, CoverKids or CoverRx are handled by the Department's TennCare Oversight Division instead.
Phone: 615-741-2218 or 1-800-342-4029. File a complaint online
Independent (external) review
- Process
- A state process. Run by Independent external review organizations under contract with your health insurer, overseen by the Tennessee Commissioner of Commerce and Insurance.
- Where you file
- insurer
- How
- Send your external review request to your health insurer, following the instructions and release form that came with your denial letter. The insurer must check the request within 10 business days and tell you in writing within 3 more business days whether it is complete and eligible. If the insurer says your request is not eligible, you can appeal that decision to the Commissioner of Commerce and Insurance (Consumer Insurance Services, 1-800-342-4029).
- Which denials qualify
- Denials of a covered service because the insurer decided it does not meet its requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness, and denials because a treatment is considered investigational (experimental). Expedited review is not available for care you have already received.
- Appeal to the plan first?
- Yes. Exceptions in state law: for a request for care not yet received, you filed a grievance and got no written decision within 30 days (unless you agreed to a delay); the insurer agrees to waive the requirement; or your situation is urgent, in which case you can ask for expedited external review at the same time as an expedited internal review. For denials of care already received you must always finish the internal process first.
Free help in Tennessee
- Tennessee Department of Commerce and Insurance, Consumer Insurance Services
Answers questions about your policy and investigates and mediates disputes over denied claims with insurers for policies written in Tennessee; listed by the federal government as Tennessee's consumer assistance resource.
Phone: 615-741-2218 or 1-800-342-4029
- Tennessee Justice Center
Nonprofit that offers free help with public health insurance programs including TennCare and CoverKids; call or use its case inquiry form to ask whether it can help with your denial.
Phone: 615-255-0331
Medicare and Medicaid in Tennessee
- Medicare counseling
- Tennessee State Health Insurance Assistance Program (TN SHIP) · 1-877-801-0044 . Free help with Medicare appeals.
- Medicaid agency
- Division of TennCare (TennCare, Tennessee's Medicaid program)
- Fair hearing deadline
- 60 days to appeal after you find out that there is a problem. Your notice states the deadline that applies to you.
- Good to know
- Medical appeals go to TennCare Member Medical Appeals, not to your health plan: call 1-800-878-3192 (they can take the appeal by phone), file online at TennCareConnect.TN.gov, mail the form to PO Box 593, Nashville, TN 37202-0593, or fax 1-888-345-5575. Appeals are usually decided within 90 days; an emergency (expedited) appeal is decided in about one week. Eligibility appeals use a separate process. TennCare's appeal page does not state the deadline for keeping services during an appeal; check your notice.
State laws that can help
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External review. Gives you six months to ask for an independent external review through your insurer, with a 40-day standard decision, a 72-hour expedited decision, the insurer paying for the review, and a right to appeal to the Commissioner if the insurer says you are not eligible.
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Step therapy. Insurers must offer a clear process to request a step therapy exception and must grant it in listed situations, such as when the required drug is likely to harm you or you are already doing well on your current drug; if the insurer does not answer in time the exception is granted.
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Prior authorization. Prior authorization decisions are due within seven calendar days (72 hours, plus one business day if applicable, for urgent care), denials must be made by a licensed physician or a professional in the same or a similar specialty, emergency services cannot require prior authorization, and approvals for chronic conditions generally last at least six months.
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Mental health parity. State-regulated individual and group health plans must cover mental health, alcoholism and drug dependency services in line with the federal Mental Health Parity and Addiction Equity Act, and must use American Society of Addiction Medicine criteria or other evidence-based guidelines when reviewing substance use treatment.
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Other. An enrollee can ask the Department of Commerce and Insurance to review whether a managed health plan's provider network is adequate, using a request form on the Department's complaint page.
Sources and what we could not confirm
- Tennessee Code § 56-61-116, Standard external review (Justia, 2025 code)
- Tennessee Code § 56-61-116 (FindLaw copy, used for subsections (k) to (q))
- Tennessee Code § 56-61-115, Exhaustion of internal grievance process
- Tennessee Code § 56-61-117, Expedited external review
- Tennessee Code § 56-61-118, External review when treatment determined to be investigational
- Tennessee Code § 56-61-124, Funding of external review
- Tennessee Code § 56-61-102, Chapter definitions
- Tennessee Department of Commerce and Insurance: Consumer Resources
- Tennessee Insurance: File an Insurance Complaint
- The Tennessee Insurance Division
- Centers for Medicare & Medicaid Services: State External Appeals Review Processes
- Centers for Medicare & Medicaid Services: Consumer Assistance Program contacts, Tennessee
- TennCare: How to file a medical appeal
- TennCare: Contact Us
- Tennessee State Health Insurance Assistance Program (TN SHIP)
- State Health Insurance Assistance Program National Technical Assistance Center: Tennessee
- Tennessee Code § 56-7-3502, Step therapy exception process
- Tennessee Code § 56-7-3704 (Prior Authorization Fairness Act)
- Tennessee General Assembly: House Bill 885 (113th General Assembly) bill information
- Tennessee Code § 56-7-2360, Coverage for mental health, alcoholism, or drug dependency services
- TennCare Oversight Division: Provider Complaint Process
- Tennessee Justice Center: Free help
Not confirmed (12)
- The official independent review page. the Department of Commerce and Insurance has no consumer page on external review that I could find, so the link goes to the statute text on Justia (an unofficial copy of the code)
- The independent review request form. no state form found; the insurer must supply instructions and a release form with the denial notice
- The cost of independent review. no official consumer page addresses a fee; the sections of the Act that were read (56-61-115 to 56-61-118, 56-61-124) set no filing fee and make the insurer pay the review organization, but the whole chapter was not read
- How long a standard independent review takes. the 40-day rule in § 56-61-116(m) was read on FindLaw's copy (marked current as of January 2, 2024); the Justia 2025 page was cut off before that subsection
- Who runs the independent review. that insurers contract with the review organizations comes from § 56-61-116(q) on the same FindLaw copy
- Which denials qualify for independent review. summarized from the statute's preliminary review test and definitions, not from a consumer page; eligibility-based denials may also qualify
- A searchable list of past decisions. no published database of past decisions found
- Published results of independent review. no officially published overturn rate found
- The state regulators. this is the Department's complaint page, which links to the online form; the direct form address was not confirmed
- Free consumer help programs. the Tennessee Justice Center page lists TennCare and CoverKids as programs it helps with but does not say it handles denials or appeals specifically
- Notes on Medicaid appeals. deadline to keep services during a TennCare appeal not found on the appeal page
- State laws that help. the public chapter number and signing date of the amending bill were not confirmed; the bill page shows the 113th General Assembly and a January 1, 2025 effective date, and the 2025 code on Justia contains the seven-day and 72-hour deadlines