[Effective 1/1/2025]

As used in this part:

(1) “Additional business day” means the first weekday not designated as a state or federal holiday;
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Terms Used In Tennessee Code 56-7-3702

  • Contract: A legal written agreement that becomes binding when signed.
  • Facility: means an institution licensed under title 33 or 68. See Tennessee Code 56-7-3702
  • Healthcare service: means a service rendered by a healthcare provider or at a practice that provides testing, monitoring, diagnosis, or treatment of a human disease or condition, or dispenses medical devices, medical appliances, or medical goods for the treatment of a human disease or condition. See Tennessee Code 56-7-3702
  • Person: means any association, aggregate of individuals, business, company, corporation, individual, joint-stock company, Lloyds-type organization, organization, partnership, receiver, reciprocal or interinsurance exchange, trustee or society. See Tennessee Code 56-16-102
  • Physician: means a medical doctor or osteopathic physician with a valid state medical license issued pursuant to title 63, chapter 6 or 9. See Tennessee Code 56-7-3702
  • Practice: means an entity formed with at least one (1) healthcare provider to provide healthcare services. See Tennessee Code 56-7-3702
  • State: when applied to the different parts of the United States, includes the District of Columbia and the several territories of the United States. See Tennessee Code 1-3-105
  • Utilization review organization: means :
    (A) A health carrier or other entity, including a designee of such carrier or entity, that reviews or issues prior authorizations for a health carrier. See Tennessee Code 56-7-3702
  • written: includes printing, typewriting, engraving, lithography, and any other mode of representing words and letters. See Tennessee Code 1-3-105
  • Year: means a calendar year, unless otherwise expressed. See Tennessee Code 1-3-105
(2) “Adverse determination” has the same meaning as defined in § 56-61-102;
(3) “Chronic condition” means a condition that has an expected duration of one (1) year or more and requires ongoing medical attention or limits activities of daily living, or both;
(4) “Commissioner” has the same meaning as defined in § 56-1-102;
(5) “Emergency healthcare services” means emergency services as defined in § 56-7-2355;
(6) “Enrollee” has the same meaning as defined in § 56-6-703;
(7) “Enrollee benefit plan” means the right to have a payment made by a health carrier for a prescription drug listed on the applicable formulary or healthcare services in accordance with coverage contained within a health benefit plan delivered, issued for delivery, or renewed in this state;
(8) “Facility” means an institution licensed under title 33 or 68;
(9) “Health carrier” has the same meaning as defined in § 56-61-102;
(10) “Healthcare prescriber” means a prescriber as defined in § 53-10-203;
(11) “Healthcare professional” has the same meaning as defined in § 56-61-102;
(12) “Healthcare provider” has the same meaning as defined in § 56-61-102;
(13) “Healthcare service” means a service rendered by a healthcare provider or at a practice that provides testing, monitoring, diagnosis, or treatment of a human disease or condition, or dispenses medical devices, medical appliances, or medical goods for the treatment of a human disease or condition;
(14) “Inpatient service” means care provided in a hospital or other type of inpatient facility where an individual is admitted and spends one (1) or more nights, depending on the individual’s medical condition;
(15) “Medically necessary” or “medical necessity” has the same meaning as defined in § 56-61-102;
(16) “Physician” means a medical doctor or osteopathic physician with a valid state medical license issued pursuant to title 63, chapter 6 or 9;
(17) “Practice” means an entity formed with at least one (1) healthcare provider to provide healthcare services;
(18) “Prescription drug” has the same meaning as defined in § 56-7-3201;
(19) “Prior authorization” means a written or oral determination made by a health carrier or utilization review organization, or an agent of such carrier or organization, that an enrollee’s receipt of a healthcare service is a covered benefit under the applicable plan and that a requirement of medical necessity or other requirements imposed by such utilization review organization as prerequisites for payment for such services have been satisfied;
(20) “Urgent care request” has the same meaning as defined in § 56-61-102; and
(21) “Utilization review organization” means:

(A) A health carrier or other entity, including a designee of such carrier or entity, that reviews or issues prior authorizations for a health carrier; and
(B) A health maintenance organization, or another individual or entity that provides, offers to provide, or administers hospital, outpatient, medical, behavioral health, prescription drug, or other health benefits to a person treated by a healthcare provider in this state under a health insurance policy, plan, or contract.
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