Skip to main content
Find a Lawyer

Tennessee Code Title 56. Insurance § 56-7-3704

Current as of January 02, 2024 | Updated by Findlaw Staff

<Text of section effective Jan. 1, 2025.>

(a)(1) For prior authorization adverse determination appeals submitted electronically, a utilization review organization shall ensure that such appeals are reviewed or made by a licensed physician or healthcare professional with the same or a similar specialty as the healthcare professional who requested the initial prior authorization. The reviewing healthcare professional shall:

(A) Possess a current and valid non-restricted license to practice in this state or another state or territory of the United States;

(B) Be knowledgeable of, and have experience providing, the healthcare services under appeal;

(C) Not have been directly involved in making the adverse determination; and

(D) Consider all known clinical aspects of the healthcare service under review, including, but not limited to, a review of all pertinent medical records provided by the enrollee's healthcare provider, and any medical literature provided.

(2) Utilization review organizations shall perform:

(A) A non-urgent prior authorization review within seven (7) calendar days; and

(B) An urgent care prior authorization review within seventy-two (72) hours, plus, if applicable, one (1) additional business day.

(3) A health carrier or utilization review organization, or a healthcare professional on its behalf, shall not receive compensation as an incentive for issuing an adverse decision.

(b)(1) Utilization review organizations shall review all prior authorization adverse determination appeals that are not submitted electronically in accordance with standards set by the National Committee on Quality Assurance.

(2) For purposes of this part, prior authorization appeals submitted via facsimile are not submitted electronically.

Previous Part of Code Next Part of Code
Back to Chapter List

Cite this article: FindLaw.com - Tennessee Code Title 56. Insurance § 56-7-3704 - last updated January 02, 2024 | https://codes.findlaw.com/tn/title-56-insurance/tn-code-sect-56-7-3704/

FindLaw Codes may not reflect the most recent version of the law in your jurisdiction. Please verify the status of the code you are researching with the state legislature before relying on it for your legal needs.

Was this helpful?

Welcome to FindLaw's Cases & Codes

A free source of state and federal court opinions, state laws, and the United States Code. For more information about the legal concepts addressed by these cases and statutes, visit FindLaw’s Learn About the Law.

Go to Learn About the Law

Latest Blog Posts

For Legal Professionals

Learn About The Law

Get help with your legal needs

FindLaw’s Learn About the Law features thousands of informational articles to help you understand your options. And if you’re ready to hire an attorney, find one in your area who can help.

Go to Learn About the Law

Need to Find an Attorney?

Search our directory by legal issue

Enter information in one or both fields (Required)

Copied to clipboard