Appeals of an electronic and non-electronic initial adverse determination

(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. Amended by 2023 Tenn. Acts, ch. 395, s 4, eff. 1/1/2025.

(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.

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.

(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.

(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.

(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.

(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.

Amended by 2023 Tenn. Acts, ch. 395, s 4, eff. 1/1/2025.