[Effective 1/1/2025]

(a) If a utilization review organization makes an adverse determination for a prior authorization of a healthcare service, then the carrier or organization shall include the following in the notification to the enrollee and the enrollee’s healthcare provider requesting the prior authorization on the enrollee’s behalf:

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Terms Used In Tennessee Code 56-7-3703

  • 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.
  • 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
  • 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
  • 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. See Tennessee Code 56-7-3702
  • 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
(1) The reasons for the adverse determination and, if applicable, related evidence-based criteria, including a description of missing or insufficient documentation or lack of coverage of the enrollee for the healthcare service;
(2) The right to appeal the adverse determination;
(3) Instructions on how to file the appeal; and
(4) Additional documentation necessary to support the appeal.
(b) An adverse determination regarding a request for prior authorization for a healthcare service must be made by a licensed physician or a healthcare professional with the same or a similar specialty as the healthcare professional requesting the prior authorization.
(c) This section does not apply to an initial adverse determination for prescription drugs that are covered under an enrollee’s benefit plan.
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