[Effective 1/1/2025]

(a) A health carrier or utilization review organization shall accept and respond electronically to prior authorization requests from a healthcare provider submitted through a secure electronic transmission as determined by the carrier or organization.
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Terms Used In Tennessee Code 56-7-3708

  • 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
(b) If a prior authorization for a prescription drug is submitted electronically using the National Council for Prescription Drug Programs (NCPDP) SCRIPT Standard for electronic prior authorization (ePA) transactions, then the health carrier or utilization review organization must accept and respond to the prior authorization request using the NCPDP SCRIPT Standard for ePA transactions.
(c) This section does not require a healthcare professional to submit prior authorization requests electronically.
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