How to appeal a health insurance denial in Tennessee
The short answer
Start with your plan’s own appeal. If the plan says no again, you can usually ask an independent reviewer to decide. Tennessee lets you ask an independent reviewer to decide, through Tennessee Department of Commerce & Insurance. The deadline to ask: within 180 days of receiving a final determination (TDCI); the statute says within six months.
Does this apply to you? State external review covers plans regulated by Tennessee: individual and Marketplace plans, and job-based plans your employer bought from an insurer. Many large employers are self-funded; their plans follow the federal external review process, and state law usually does not apply (29 CFR 2590.715-2719(c)(1)). Medicare, Medicaid, TRICARE and federal employee plans have their own appeals: see the plan guides.
External review in Tennessee
Within 180 days of receiving a final determination (TDCI); the statute says within six months
The external review organization must decide within 72 hours of receiving an eligible expedited request. You can request it when you get the denial if you have also filed an expedited internal grievance, or after a final denial if the standard timeline would seriously jeopardize your health or you are still hospitalized after emergency care.
Free
State-regulated plans (insurance bought in Tennessee or through an employer that buys insurance). Self-funded employer plans use the federal process.
Send a written request to your health carrier, not TDCI, and sign the medical-records release it requires; there is no state form or portal. The carrier assigns one of its contracted, TDCI-approved review organizations, and TDCI can overrule a carrier's finding that your case is ineligible. TDCI consumer line: 615-741-2218 or 800-342-4029.
Who to contact
Before external review: the internal appeal
External review usually comes after your plan’s own appeal. The deadline for that first appeal depends on the type of plan:
- Employer plan: 180 days from the day you receive the denial notice
- Marketplace plan: 180 days from the day you receive the denial notice
- Medicare Advantage: 60 days from when you receive the denial (counted as 65 days from the notice date)
- Medicare Part D: 60 days from when you receive the denial (counted as 65 days from the notice date)
- Original Medicare: 120 days from when you receive the notice (counted as 125 days from the notice date)
- Medicaid: 60 days from the date printed on the denial notice
- FEHB (federal employees): 6 months from the date of the denial notice
- TRICARE: Mail within 90 days after the date of the denial notice
Questions people ask
How long do I have to ask for an external review in Tennessee?
Within 180 days of receiving a final determination (TDCI); the statute says within six months
Can I get a fast external review in Tennessee?
The external review organization must decide within 72 hours of receiving an eligible expedited request. You can request it when you get the denial if you have also filed an expedited internal grievance, or after a final denial if the standard timeline would seriously jeopardize your health or you are still hospitalized after emergency care.
Does external review cost anything in Tennessee?
Free
Do Tennessee’s rules apply to my job-based plan?
Only if the plan is fully insured, meaning your employer bought a policy from an insurance company. Self-funded employer plans generally follow the federal external review process instead. Your Summary Plan Description or HR benefits team can tell you which kind you have.
Sources
- TDCI External Review Disclosure Requirements (TCA 56-61-125)
the covered person must submit a written request to the health carrier within 180 days of receiving a final determination or final determination notice.
- Tenn. Code Ann. 56-61-116 (Standard external review)
Within six (6) months after the date of receipt of a notice of an adverse determination or final adverse determination
- Tenn. Code Ann. 56-61-117 (Expedited external review)
but in no event more than seventy-two (72) hours after the date of receipt of the request for an expedited external review
This page is general information about appeal rules in the United States. It is not legal or medical advice. Rules can change, and your plan’s documents and your denial letter control the dates that apply to you.