Tennessee Health Insurance Appeals and Grievances

What is an internal appeal?

An internal appeal asks the health plan to reconsider an adverse determination—when the plan denies PA, reduces payment, or says care is not medically necessary or not a covered benefit.

This is different from external review, where an independent review organization (IRO) reviews the case after internal review is complete.

General walkthrough: Appeals roadmap.

Tennessee appeal timelines

Chapter 56-61 (health carrier grievances)

Tennessee's Health Carrier Grievance and External Review Procedure Act (Ch. 56-61) sets grievance and appeal procedures for regulated health carriers. For most non-grandfathered plans aligned with federal standards:

• First-level appeal — pre-service: decision within 30 days (§ 56-61-107)
• First-level appeal — post-service (reimbursement): within 60 days
• Second-level review (optional): you may request an in-person review panel; meeting within 60 business days; written decision within 5 business days after the meeting (§ 56-61-108)
• Urgent appeals: as fast as the medical condition requires, not more than 72 hours after receipt of the request (§ 56-61-109)

Deemed exhaustion (§ 56-61-115)

You may proceed to external review without waiting further if:

• The carrier fails to issue a timely internal appeal decision after receiving all necessary information (and you did not agree to a delay)
• The carrier waives internal appeal
• The carrier materially fails to follow required internal appeal procedures

Final adverse determination notice

Your notice must explain external review rights and include TDCI contact information (§ 56-61-125). File external review with your carrier within six months of the final denial (§ 56-61-114).

How to file

1. Read the denial for appeal instructions and deadlines.
2. Submit in writing when possible—include member ID, claim number, and clinical support.
3. Request expedited review if delay would cause serious harm.
4. Consider second-level review if offered and you want an in-person panel hearing.
5. Keep copies of everything sent and the date sent.

Carrier links: Tennessee prior auth & internal appeals links.

Evidence that helps

• Treating clinician letter on medical necessity
• Insurer's clinical criteria (request in writing if not provided)
• Peer-reviewed literature for experimental/investigational disputes

See Building a strong appeal packet.

Medicaid appeals

TennCare medical benefit appeals use a state fair hearing process—not commercial Ch. 56-61 review:

• File within 60 days from when you learn of the problem (TennCare — medical appeal) · 800-878-3192 · P.O. Box 593, Nashville, TN 37202-0593
• Call your MCO first; TennCare's process includes MCO reconsideration before a state fair hearing
• Standard decision often within about 90 days; expedited appeals (~1 week) when delay would endanger life or health
• Eligibility appeals (coverage denied or terminated): 40 calendar days from the notice (TennCare — eligibility appeal) · TennCare Connect 855-259-0701

More: Medicaid managed care appeals.

After internal appeal

If you receive a final denial, request external review in writing to your health carrier within six months (§ 56-61-114).

Next: Tennessee external review.