[Effective 1/1/2025]

(a) Upon receipt of information documenting a prior authorization from the enrollee or from the enrollee’s healthcare provider, a prior authorization granted to an enrollee from a previous utilization review organization or health carrier must be honored for at least the initial ninety (90) days of an enrollee’s coverage under a new health benefit plan.

Terms Used In Tennessee Code 56-7-3714

  • 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
  • Remainder: An interest in property that takes effect in the future at a specified time or after the occurrence of some event, such as the death of a life tenant.
  • 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
  • Year: means a calendar year, unless otherwise expressed. See Tennessee Code 1-3-105
(b) During the time period described under subsection (a), a health carrier or utilization review organization may perform its own review to approve or deny the prior authorization approved by the enrollee’s previous health benefit plan effective when the initial ninety-day period expires.
(c) If there is a change in coverage of, or approval criteria for, a previously authorized healthcare service, then the change in coverage or approval criteria must not affect an enrollee who received prior authorization before the effective date of the change for the remainder of the enrollee’s health benefit plan year.
(d) A health carrier or utilization review organization shall continue to honor a prior authorization it has granted to an enrollee when the enrollee changes plans carried or administered by the same health carrier.
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