Tenn. Code Ann. § 56-7-3707: Clinical criteria

(a) A health carrier shall maintain a complete list of healthcare services for which a prior authorization is required. (b) The clinical review criteria for healthcare services or prescription drugs requiring prior authorization must: (1) Be based on nationally recognized, generally accepted standards for national, clinical criteria, except where state law provides its own standard; (2) Not be arbitrary and must be cited by the utilization review organization; (3) Be developed in accordance with the current standards of a national medical accreditation entity; (4) Ensure quality of care and access to needed healthcare services; (5) Be evidence-based; (6) Be sufficiently flexible to allow deviations from norms when justified on a case-by-case basis; and (7) Be evaluated and updated in accordance with § 56-7-3718 . (c) A claim for failure to obtain prior authorization must not be denied if the prior authorization requirement was not in effect on the date of service on the claim. Amended by 2023 Tenn. Acts, ch. 395, s 4, eff. 1/1/2025.

(a) A health carrier shall maintain a complete list of healthcare services for which a prior authorization is required.

(b) The clinical review criteria for healthcare services or prescription drugs requiring prior authorization must: (1) Be based on nationally recognized, generally accepted standards for national, clinical criteria, except where state law provides its own standard; (2) Not be arbitrary and must be cited by the utilization review organization; (3) Be developed in accordance with the current standards of a national medical accreditation entity; (4) Ensure quality of care and access to needed healthcare services; (5) Be evidence-based; (6) Be sufficiently flexible to allow deviations from norms when justified on a case-by-case basis; and (7) Be evaluated and updated in accordance with § 56-7-3718 .

(1) Be based on nationally recognized, generally accepted standards for national, clinical criteria, except where state law provides its own standard;

(2) Not be arbitrary and must be cited by the utilization review organization;

(3) Be developed in accordance with the current standards of a national medical accreditation entity;

(4) Ensure quality of care and access to needed healthcare services;

(5) Be evidence-based;

(6) Be sufficiently flexible to allow deviations from norms when justified on a case-by-case basis; and

(7) Be evaluated and updated in accordance with § 56-7-3718 .

(c) A claim for failure to obtain prior authorization must not be denied if the prior authorization requirement was not in effect on the date of service on the claim.