[Effective 1/1/2025]

A health carrier or utilization review organization requiring prior authorization shall make de-identified aggregate statistics available by service code regarding prior authorization approvals and denials on its website in a readily accessible format. The commissioner shall determine the information required in order to comply with this section and in accordance with applicable state and federal privacy laws. Such statistics include, but are not limited to:

(1) The number of initial prior authorization requests that were approved or denied during the previous benefit plan year by the health carrier or utilization review organization;

Terms Used In Tennessee Code 56-7-3717

  • Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
  • Code: includes the Tennessee Code and all amendments and revisions to the code and all additions and supplements to the code. See Tennessee Code 1-3-105
  • Commissioner: means the commissioner of commerce and insurance. See Tennessee Code 56-1-102
  • 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
  • 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
(2) The number of prior authorization requests that were appealed;
(3) The number of appeals overturned and the number granted;
(4) The time between submission of an initial prior authorization request and response;
(5) The top five (5) reasons for denial;
(6) The average time between submission and response for an initial prior authorization request;
(7) The average time between submission and response for an appeal of a prior authorization denial; and
(8) Any other information that the commissioner determines appropriate.
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