(a) A health carrier is responsible for monitoring all utilization review activities performed on its behalf and for ensuring that all requirements of this chapter and applicable rules are met.
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 health carrier shall ensure that appropriate personnel have operational responsibility for the conduct of the utilization review program.(c) Whenever a health carrier contracts with a utilization review organization to perform services subject to this part or applicable rules, the commissioner shall hold the health carrier responsible for monitoring the activities of such utilization review organization and for ensuring that the requirements of this part and applicable rules are met.(d) A utilization review organization shall use clinical criteria as specified in § 56-7-3707(b).
