(a) A prior authorization request under this section that has not been submitted as an urgent care request by the healthcare provider is deemed approved within seven (7) calendar days, or after the date and time of submission if the health carrier or utilization review organization, or its designee:
Terms Used In Tennessee Code 56-7-3705
Additional business day: means the first weekday not designated as a state or federal holiday. See Tennessee Code 56-7-3702
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
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) Fails to approve or deny the request;(2) Fails to request from the healthcare provider all additional information needed to make a decision; or(3) Except for a prior authorization for a prescription drug, fails to notify the healthcare provider that prior authorization is being questioned for medical necessity.(b) The utilization review organization has an additional five (5) calendar days to process the prior authorization once the healthcare provider submits the requested additional information.(c) Except as provided in subsection (e), the prior authorization request process must not exceed seventeen (17) calendar days. Failure by a healthcare provider to submit the required documentation within seventeen (17) days necessitates the provider requesting a new prior authorization.(d) If notice is provided pursuant to subdivision (a)(3), then the notice must include the following:
(1) A direct phone number to the utilization review organization;(2) Hours of business operation of the utilization review organization’s physician with decision-making authority to review the prior authorization; and(3) A statement that there is an opportunity to discuss the medical necessity of the healthcare service directly with the healthcare professional who will be responsible for approving or denying the prior authorization of the healthcare service under review.(e) If a notice complies with subdivision (d), then the prior authorization request process must not exceed seventeen (17) days. Failure by a healthcare provider to submit the required documentation within seventeen (17) days necessitates the provider requesting a new prior authorization.(f) A prior authorization request under this section that has been submitted as an urgent care request by the healthcare provider is deemed approved by the utilization review organization if the utilization review organization fails to approve or deny the request, or request all additional information needed to make a decision within seventy-two (72) hours plus, if applicable, one (1) additional business day, after the date and time of submission of the prior authorization request. The healthcare provider shall submit requested additional information within seventy-two (72) hours, plus, if applicable, one (1) additional business day, of receiving a request for additional information. If additional information is requested, then the prior authorization request is deemed approved by the health carrier or utilization review organization if it fails to grant the request, deny the request, or otherwise respond to the request of the healthcare provider within seventy-two (72) hours, plus, if applicable, one (1) additional business day, after the date and time of the submission for all requested additional information. Failure by a provider to submit the required documentation within seventy-two (72) hours, plus, if applicable, one (1) additional business day, necessitates the healthcare provider requesting a new prior authorization.(g) A health carrier that provides coverage for emergency services in an emergency department of a hospital or freestanding emergency room facility shall comply with § 56-7-2355 and shall not require a prior authorization for such emergency services.(h) A healthcare professional must submit a request for a prior authorization at least five (5) calendar days prior to the provision of the service or therapy for non-urgent prior authorizations.(i) This section applies only to electronic submissions, unless the utilization review organization or health carrier does not allow electronic submission of prior authorizations.(j) For the purposes of this section, health carriers are not required to provide the notice in accordance with § 56-7-3703 in writing.
