[Effective 1/1/2025]

(a) If a prior authorization is required for a healthcare service for the treatment of a chronic condition of an enrollee, then the prior authorization remains valid for at least six (6) months, from the date the healthcare professional or provider receives the prior authorization approval, unless the clinical criteria as specified in § 56-7-3707 state otherwise.

Terms Used In Tennessee Code 56-7-3706

  • Chronic condition: means a condition that has an expected duration of one (1) year or more and requires ongoing medical attention or limits activities of daily living, or both. See Tennessee Code 56-7-3702
  • 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
  • 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
(b) If prior authorization is required for a prescription drug for the treatment of a chronic condition of an enrollee, then the prior authorization remains valid for at least six (6) months from the date the healthcare professional or provider receives the prior authorization approval, unless the clinical criteria as specified in § 56-7-3707 state otherwise.
(c) This section does not apply to the requirements of a prior authorization for the prescription of a schedule II, III, IV, or V drug. However, notice must be given to the healthcare provider pursuant to this section if prior authorization is or may be required for a schedule II, III, IV or V drug.
(d) This section does not require a policy of health insurance coverage to cover care, treatment, or services for a health condition that the terms of coverage otherwise completely exclude from the policy’s covered benefits without regard for whether the care, treatment, or services are medically necessary.
(e) This section does not apply to inpatient services.
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