The Rules of Tennessee Department of Finance and Administration Bureau of TennCare for both Medicaid and Standard use the following definition: "Emergency Medical Condition, including emergency mental health and substance abuse emergency treatment services, shall mean the sudden and unexpected onset of a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent lay person who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to potentially result in: (a) Placing the person's (or with respect to a pregnant woman, her unborn child's) health in serious hexapody; or (b) Serious impairment to bodily functions: or (c) Serious dysfunction of any bodily organ or part. If an enrollee files an appeal and states that it is an "emergency" appeal, meaning the case will be processed on a short timeline, the physician will be asked to certify whether or not the request for service is in fact an emergency. By signing this document certifying that an emergency appeal is needed, the physician is certifying that the amount of time needed to resolve the appeal should be expedited. Waiting places the enrollee at risk of serious health problems or death, severe impairment of bodily organs or parts, or hospitalization as a result of such a delay.
While TLC believes that the PCCM is the anchor of our Members’ care, please note that Emergency services are available 24 hours a day, 7 days a week, and do not require authorization of any kind.

Utilization Management (UM) decision making is based solely on medical appropriateness of care and service, which includes the existence of coverage. TLC does not reward practitioners or other individuals for issuing denials of coverage, service or care. There are no financial incentives for UM decision makers to make decisions that result in underutilization.

The UM department is staffed with professional nurses who work with physicians to achieve effective and appropriate use of health care resources. TLC nurse reviewers evaluate all requests for services utilizing nationally recognized and accepted utilization management criteria (InterQual) guidelines and protocols, and criteria developed by Schaller Anderson of Tennessee. The criteria are used as a screening tool only to assist the nurse in knowing when to refer the case to a physician reviewer. Nurse reviewers do not render adverse determinations. If a requested service does not meet criteria, the case will be referred to a TLC physician reviewer.

TLC has a physician available to discuss medical necessity denials with the treating or attending practitioner. Additionally, copies of criteria used for screening are available to all Practitioners upon request. Discussion with the TLC physician and/or copies of the criteria can be obtained by calling the TLC UM Department at 725-7100 (Shelby County) or 800-473-6523 (outside of Shelby County). Follow the prompts for the UM Department. This number is answered 24 hours/day, 7 days/week.