Free Medical Plans Study Guide
Tennessee Accident & Health exam — Medical Plans.
The national Medical Plans guide covers plan types, cost sharing and the ACA. This guide covers the Tennessee rules that attach to health coverage: newborn coverage, prompt pay, external review, parity and telehealth. Policy provisions are in the Tennessee Individual A&H Provisions guide, and group rules are in the Tennessee Group Health guide.
Newborns (Tenn. Code Ann. 56-7-2301)
- Coverage for a newborn starts from the moment of birth.
- It includes injury and sickness, plus medically diagnosed congenital defects and birth abnormalities. It isn't just well-baby care.
- If a specific premium is charged for the child, the policy may require notice and payment within 31 days of birth for coverage to continue past that point.
Prompt pay (56-7-109)
| Claim type | Pay or properly deny within |
|---|---|
| Clean electronic claim | 21 calendar days |
| Clean paper claim | 30 calendar days |
Late clean claims earn interest of 1% per month, starting the day after payment was due.
Appeals and external review (56-61-113, 56-61-116)
- Denial notices must explain the member's right to have the decision reviewed by independent health care professionals with no connection to the carrier.
- The member has 6 months after an adverse or final adverse determination to request external review.
- The external review organization decides within 40 days.
- The carrier pays for the review. If its denial is reversed, it must approve coverage immediately.
Other required benefits
- Mental health and substance use benefits must be consistent with the federal Mental Health Parity and Addiction Equity Act (56-7-2360).
- Telehealth: a covered service can't be excluded just because it was delivered by telehealth instead of in person (56-7-1002).
Free look and marketing
- An individual health policy may be returned within 10 days of delivery for a full refund (56-26-129).
- Describing a limited policy as comprehensive major medical is misrepresentation (56-8-104).
- HMO agents need a producer license with the accident and health line (Rule 0780-01-56-.10).
Common exam traps
- Newborns are covered from birth. Notice and premium may be required within 31 days.
- Clean claims: 21 days electronic, 30 days paper. Late payment earns 1% a month.
- External review: request within 6 months, decision within 40 days, and the carrier pays for it.
Practice Medical Plans questions All Accident & Health topics
Practice questions are study aids generated for exam preparation and are not actual exam questions. Content is provided for educational purposes and is not legal advice. Verify current statutes, rules, and exam specifications with the Insurance Department and the exam administrator before relying on it.
