(a) Whenever the commissioner has reason to believe that a utilization review agent subject to this part has been or is engaged in conduct that violates this part, the commissioner shall notify the utilization review agent of the alleged violation. The utilization review agent has thirty (30) days from the date the notice is received to respond to the alleged violation.
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
(b) If the commissioner believes the utilization review agent has violated this part, or is not satisfied that the alleged violation has been corrected, the commissioner may conduct a contested case hearing on the alleged violation in accordance with the Uniform Administrative Procedures Act, compiled in title 4, chapter 5.(c) If, after the hearing, the commissioner determines that the utilization review agent has engaged in violations of this part, the commissioner shall reduce the findings to writing and shall issue and cause to be served upon the utilization review agent a copy of the findings and an order requiring the utilization review agent to cease and desist from engaging in the violations. The commissioner may also, at the commissioner’s discretion, order:
(1) Payment of a penalty of not more than ten thousand dollars ($10,000) in the aggregate for a violation that occurred with such frequency as to indicate a general business pattern or practice; or(2) Suspension or revocation of the authority to do business in this state as a utilization review agent if the utilization review agent knew the act was in violation of this chapter and repeated the act with such frequency as to indicate a general business pattern or practice.
