[Effective 1/1/2025]

(a) A utilization review organization shall not deem as incidental or deny claims for supplies or healthcare services that are routinely used as part of a healthcare service when:

Terms Used In Tennessee Code 56-7-3715

  • 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) A closely related service has received prior authorization; or
(2) Prior authorization for the healthcare service is not required.
(b) As used in this section, “closely related service” means a similar service to the service allowed by prior authorization and required by the standard of care.
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