(a) A utilization review organization shall provide notice to healthcare providers in its network of each new prior authorization requirement, or restriction or amendment to an existing prior authorization requirement, at least sixty (60) days prior to the effective date of the change.
Terms Used In Tennessee Code 56-7-3712
Amendment: A proposal to alter the text of a pending bill or other measure by striking out some of it, by inserting new language, or both. Before an amendment becomes part of the measure, thelegislature must agree to it.
Contract: A legal written agreement that becomes binding when signed.
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
United States: includes the District of Columbia and the several territories of the United States. See Tennessee Code 1-3-105
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
written: includes printing, typewriting, engraving, lithography, and any other mode of representing words and letters. See Tennessee Code 1-3-105
(b) A utilization review organization shall provide notice to healthcare providers in its network of each new prior authorization requirement, or restriction or amendment to an existing prior authorization requirement, for a prescription drug at least forty-five (45) days prior to the effective date of the change unless any of the following apply:
(1) The United States food and drug administration has:
(A) Issued a statement that calls into question the clinical safety of the drug;(B) Required the manufacturers to conduct post-market safety studies and clinical trials after the approval of the drug;(C) Issued any drug safety-related labeling changes; or(D) Required the manufacturers to implement special risk management programs;(2) The drug receives a new approval from the United States food and drug administration and has become available; or(3) The United States food and drug administration has approved expanded use of the drug.(c) Notice required by this section must be distributed through:
(1) The utilization review organization’s website or the healthcare provider’s portal; and(2)Written communication sent to a dedicated email address and regular mailing address for the healthcare provider or as stipulated in the contract between the healthcare provider and the utilization review organization. The healthcare provider may be required to submit a dedicated email address and regular mailing address to receive the notices required by this subsection (c).
