[Effective 1/1/2025]

The purpose of this part is to:

(1) Promote the delivery of quality health care in a cost-effective manner;
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Terms Used In Tennessee Code 56-6-702 v2

  • Utilization review: means a system for prospective and concurrent review of the necessity and appropriateness in the allocation of health care resources and services given or proposed to be given to an individual within this state. See Tennessee Code 56-6-703
(2) Assure that utilization review agents adhere to reasonable standards for utilization review, including adherence to the Prior Authorization Fairness Act, compiled in chapter 7, part 37 of this title;
(3) Foster greater coordination and cooperation between healthcare providers and utilization review agents, including adherence to the Prior Authorization Fairness Act;
(4) Improve communications and knowledge of benefit plan requirements among all parties concerned before expenses are incurred; and
(5) Ensure that utilization review agents and procedures maintain and safeguard the confidentiality of all health-related records, especially mental health and chemical dependency disorders, in accordance with applicable laws and requirements of nationally recognized review accreditation bodies such as the Health Insurance Portability and Accountability Act (HIPAA) and the utilization review accreditation commission (URAC).
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