[Effective 1/1/2025]

(a) A health carrier shall maintain a complete list of healthcare services for which a prior authorization is required.

Terms Used In Tennessee Code 56-7-3707

  • 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
  • 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) The clinical review criteria for healthcare services or prescription drugs requiring prior authorization must:

(1) Be based on nationally recognized, generally accepted standards for national, clinical criteria, except where state law provides its own standard;
(2) Not be arbitrary and must be cited by the utilization review organization;
(3) Be developed in accordance with the current standards of a national medical accreditation entity;
(4) Ensure quality of care and access to needed healthcare services;
(5) Be evidence-based;
(6) Be sufficiently flexible to allow deviations from norms when justified on a case-by-case basis; and
(7) Be evaluated and updated in accordance with § 56-7-3718.
(c) A claim for failure to obtain prior authorization must not be denied if the prior authorization requirement was not in effect on the date of service on the claim.
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