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
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
Practice: means an entity formed with at least one (1) healthcare provider to provide healthcare services. 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
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
written: includes printing, typewriting, engraving, lithography, and any other mode of representing words and letters. See Tennessee Code 1-3-105
(2) “Adverse determination” has the same meaning as defined in § 56-61-102;(3) “Chronic condition” means a condition that has an expected duration of one (1) year or more and requires ongoing medical attention or limits activities of daily living, or both;(4) “Commissioner” has the same meaning as defined in § 56-1-102;(5) “Emergency healthcare services” means emergency services as defined in § 56-7-2355;(6) “Enrollee” has the same meaning as defined in § 56-6-703;(7) “Enrollee benefit plan” means the right to have a payment made by a health carrier for a prescription drug listed on the applicable formulary or healthcare services in accordance with coverage contained within a health benefit plan delivered, issued for delivery, or renewed in this state;(8) “Facility” means an institution licensed under title 33 or 68;(9) “Health carrier” has the same meaning as defined in § 56-61-102;(10) “Healthcare prescriber” means a prescriber as defined in § 53-10-203;(11) “Healthcare professional” has the same meaning as defined in § 56-61-102;(12) “Healthcare provider” has the same meaning as defined in § 56-61-102;(13) “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;(14) “Inpatient service” means care provided in a hospital or other type of inpatient facility where an individual is admitted and spends one (1) or more nights, depending on the individual’s medical condition;(15) “Medically necessary” or “medical necessity” has the same meaning as defined in § 56-61-102;(16) “Physician” means a medical doctor or osteopathic physician with a valid state medical license issued pursuant to title 63, chapter 6 or 9;(17) “Practice” means an entity formed with at least one (1) healthcare provider to provide healthcare services;(18) “Prescription drug” has the same meaning as defined in § 56-7-3201;(19) “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;(20) “Urgent care request” has the same meaning as defined in § 56-61-102; and(21) “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; and(B) A health maintenance organization, or another individual or entity that provides, offers to provide, or administers hospital, outpatient, medical, behavioral health, prescription drug, or other health benefits to a person treated by a healthcare provider in this state under a health insurance policy, plan, or contract.
