(a) Utilization review agents shall adhere to the minimum standards set forth in § 56-6-705. Utilization review programs for the mental health and chemical dependency care must comply with the most recent requirements of nationally recognized utilization review accrediting bodies, i.e., the utilization review accreditation commission (URAC) and the national committee for quality assurance (NCQA), if the agent is accredited and with all final security and privacy rules on protected health information as defined in the Health Insurance Portability and Accountability Act (HIPAA). However, nothing in this part shall be construed to require compliance with the final security and privacy rules of HIPAA prior to the compliance dates set by the secretary of health and human services.
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Terms Used In Tennessee Code 56-6-704

  • Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
  • Commissioner: means the commissioner of commerce and insurance. See Tennessee Code 56-6-703
  • Department: means the department of commerce and insurance. See Tennessee Code 56-1-102
  • 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
  • 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: 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
  • Utilization review agent: means any person or entity, including the state, performing utilization review, except:
    (A) An agency of the federal government. See Tennessee Code 56-6-703
  • Year: means a calendar year, unless otherwise expressed. See Tennessee Code 1-3-105
(b)

(1) A utilization review agent may not conduct utilization review in this state unless the utilization review agent has certified to the commissioner in writing that the agent is in compliance with § 56-6-705. Certification shall be made annually on or before July 1 of each calendar year. In addition, a utilization review agent shall file the following information:

(A) The name, address, telephone number, and normal business hours of the utilization review agent;
(B) The name and telephone number of a person for the commissioner to contact;
(C) A description of the appeal procedures for utilization review determinations; and
(D) Utilization review programs for mental health and chemical dependency care shall make available to a provider submitting patient utilization review information a description of utilization review standards and procedures applicable to that provider.
(2) Any material changes in the information filed in accordance with this section shall be filed with the commissioner within thirty (30) days of the change.
(c) Upon filing the certification, each utilization review agent shall pay an annual fee in the amount of one thousand dollars ($1,000) to the department. The commissioner shall exempt from payment of the annual fee any utilization review agent that has received accreditation by URAC or NCQA. All fees paid to the department under this part shall be held by the commissioner as expendable receipts for the purpose of administering this part.
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