[Effective 1/1/2025]

(a) A health carrier or utilization review organization shall pay a healthcare provider at the contracted payment rate for a healthcare service provided by the healthcare provider per an approved prior authorization unless:

Terms Used In Tennessee Code 56-7-3713

  • 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) The healthcare provider knowingly and materially misrepresented the healthcare service in the prior authorization request with the specific intent to deceive and obtain an unlawful payment from the health carrier;
(2) The healthcare provider was no longer contracted with the patient’s health benefit plan on the date the healthcare service was provided;
(3) The healthcare provider failed to meet the timely filing requirements of the health carrier; or
(4) The health carrier does not have liability for a claim.
(b) A health carrier shall pay a healthcare provider for performing a healthcare service if the prior authorization for the service was obtained by another healthcare provider.
(c) The health carrier shall provide reimbursement for healthcare services retroactively deemed medically necessary, regardless of when prior authorization was approved, for a maximum period of eighteen (18) months.
(d) Payment must be guaranteed when a prior authorization submitted under § 56-7-3705 is approved.
(e) This section does not apply to prescription drugs that are covered under an enrollee’s benefit plan.
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