[Effective 1/1/2025]

(a)

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Terms Used In Tennessee Code 56-7-3704

  • Additional business day: means the first weekday not designated as a state or federal holiday. See Tennessee Code 56-7-3702
  • 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
  • Practice: means an entity formed with at least one (1) healthcare provider to provide healthcare services. 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
  • 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
  • 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
(1) For prior authorization adverse determination appeals submitted electronically, a utilization review organization shall ensure that such appeals are reviewed or made by a licensed physician or healthcare professional with the same or a similar specialty as the healthcare professional who requested the initial prior authorization. The reviewing healthcare professional shall:

(A) Possess a current and valid non-restricted license to practice in this state or another state or territory of the United States;
(B) Be knowledgeable of, and have experience providing, the healthcare services under appeal;
(C) Not have been directly involved in making the adverse determination; and
(D) Consider all known clinical aspects of the healthcare service under review, including, but not limited to, a review of all pertinent medical records provided by the enrollee’s healthcare provider, and any medical literature provided.
(2) Utilization review organizations shall perform:

(A) A non-urgent prior authorization review within seven (7) calendar days; and
(B) An urgent care prior authorization review within seventy-two (72) hours, plus, if applicable, one (1) additional business day.
(3) A health carrier or utilization review organization, or a healthcare professional on its behalf, shall not receive compensation as an incentive for issuing an adverse decision.
(b)

(1) Utilization review organizations shall review all prior authorization adverse determination appeals that are not submitted electronically in accordance with standards set by the National Committee on Quality Assurance.
(2) For purposes of this part, prior authorization appeals submitted via facsimile are not submitted electronically.
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