Tennessee State Government
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STATE OF TENNESSEE
DEPARTMENT OF COMMERCE AND INSURANCE
Tennessee Health Carrier Grievance Reporting Register Instructions:
According to Tennessee Code Ann. 56-61-105, (e) (2) (A), A health carrier shall submit to the commissioner, at least annually, a report to document grievances in the format specified by the commissioner.
(B) The report shall include for each type of health benefit plan offered by the health carrier:
(i) The number of covered lives that fall under this chapter's protections;
(ii) The total number of grievances;
(iii) The number of grievances for which a covered person and healthcare provider requested a second level voluntary grievance review pursuant to § 56-61-108;
(iv) The number of grievances resolved at each level, if applicable, and their resolution; and
(v) A synopsis of actions being taken to correct problems identified.
The form must be submitted to the Department by October 1st of the year following the reporting year.
Please submit the report via email to Inspolicy.Analysis@.
If you have any questions please contact:
Mary Freeman, Policy Analyst
Policy Analysis Section
Phone: 615-532-2205
Email: Mary.Freeman@
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STATE OF TENNESSEE
DEPARTMENT OF COMMERCE AND INSURANCE
INSURANCE DIVISION – POLICY ANALYSIS SECTION
500 James Robertson Parkway, Fourth Floor
Nashville, TN 37243-1130
Phone: (615) 741-2825 Fax: (615) 741-0648
Tennessee Health Carrier Grievance Reporting Register
DATE ______/______/______
Name of Company: ____________________________________________________________________
NAIC Number: _________________________ Reporting Year: __________________
Street Address ________________________________________________________________________
City ___________________________________________ State _________ Zip Code_______________
Telephone (________) _______-___________ Email ______________________________________
INDIVIDUAL
| | | | |Grievances | | | | | | | | | | |Covered | | 1st Level | | | | 2nd Level | | | | External Review | | | | |Lives | |Upheld |Overturned |Total | |Upheld |Overturned |Total | |Upheld |Overturned |Total | | | | | | | | | | | | | | | | |PPO | | | | | | | | | | | | | | |POS | | | | | | | | | | | | | | |EPO | | | | | | | | | | | | | | |HSA | | | | | | | | | | | | | | |HDHP | | | | | | | | | | | | | | |FFS | | | | | | | | | | | | | | |HMO | | | | | | | | | | | | | | |Total | | | | | | | | | | | | | | |
SMALL GROUP (2 – 50 employees)
| | | | |Grievances | | | | | | | | | | |Covered | | 1st Level | | | | 2nd Level | | | | External Review | | | | |Lives | |Upheld |Overturned |Total | |Upheld |Overturned |Total | |Upheld |Overturned |Total | | | | | | | | | | | | | | | | |PPO | | | | | | | | | | | | | | |POS | | | | | | | | | | | | | | |EPO | | | | | | | | | | | | | | |HSA | | | | | | | | | | | | | | |HDHP | | | | | | | | | | | | | | |FFS | | | | | | | | | | | | | | |HMO | | | | | | | | | | | | | | |Total | | | | | | | | | | | | | | |
LARGE GROUP (> 50 employees)
| | | | |Grievances | | | | | | | | | | |Covered | | 1st Level | | | | 2nd Level | | | | External Review | | | | |Lives | |Upheld |Overturned |Total | |Upheld |Overturned |Total | |Upheld |Overturned |Total | | | | | | | | | | | | | | | | |PPO | | | | | | | | | | | | | | |POS | | | | | | | | | | | | | | |EPO | | | | | | | | | | | | | | |HSA | | | | | | | | | | | | | | |HDHP | | | | | | | | | | | | | | |FFS | | | | | | | | | | | | | | |HMO | | | | | | | | | | | | | | |Total | | | | | | | | | | | | | | |
Synopsis of actions being taken to correct problems identified:
Print Name__________________________________________ Title__________________________________
Signature _________________________________________________________________________________
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