2023 Tennessee Code › Title 56 - INSURANCE (§§ 56-1-101 — 56-61-125) › Chapter 6 - AGENTS, SOLICITORS AND ADMINISTRATORS (§§ 56-6-101 — 56-6-1407) › Part 7 - HEALTH CARE SERVICE UTILIZATION REVIEW ACT (§§ 56-6-701 — 56-6-706) › Section 56-6-705 - Utilization review agents - Minimum standards

(a)
All utilization review agents shall meet the following minimum standards:
(1)
Notification of a determination by the utilization review agent shall be mailed or otherwise communicated to the provider of record or the enrollee or other appropriate individual within two (2) business days of the receipt of the request for determination and the receipt of all information necessary to complete the review;
(2)
(A)
Any restrictions, preauthorizations, adverse determinations, or final adverse determinations that a utilization review agent places on the preauthorization of health care services shall be based on the medical necessity or appropriateness of those services and shall be based on written clinical criteria;
(B)
Utilization review agents shall apply written clinical criteria consistently. Written clinical criteria shall:
(i)
Be based on:
(a)
Nationally recognized standards including, but not limited to, the standards published by the American College of Cardiology, MCG, Hayes, Inc., or ODG; provided, however, that when multiple standards addressing the same treatment protocol exist, the payer shall have the right to select the standard upon which the written clinical criteria will be based; or
(b)
Standards developed pursuant to §
50-6-124
;
(ii)
Be developed in accordance with the current standards of national accreditation entities or with standards developed pursuant to §
50-6-124
;
(iii)
Ensure quality of care and access to needed health care services;
(iv)
Be evidence-based; and
(v)
Be evaluated and updated at least annually;
(C)
A utilization review agent shall make any current preauthorization requirements and restrictions available on its online provider portal. The utilization review agent shall cite to the standards being used and reference the section of the standards relied upon by the utilization review agent. If the utilization review agent is relying upon proprietary references and documentation in developing the clinical criteria, then the utilization review agent shall provide a citation to the proprietary clinical indications being used. Any nonproprietary supporting references and documentation shall be made available to contracted providers if the utilization review agent develops its own clinical criteria; and
(D)
If a utilization review agent intends to either implement a new preauthorization requirement or restriction, or amend an existing requirement or restriction, the utilization review agent shall provide contracted health care providers with written notice, or other form of notice under the terms of the contract, of the new or amended requirement or restriction no less than sixty (60) days before the requirement or restriction is implemented and shall ensure that such restriction or requirement has been updated on the utilization review agent's web site;
(3)
Any notification of determination not to certify an admission or service or procedure must include the principal reason for the determination and the procedures to initiate an appeal of the determination;
(4)
If the utilization review agent requires additional information from an enrollee, a provider, or healthcare facility to make a determination on a request for prior authorization, then, no later than five (5) business days after receipt of the request, the agent shall notify:
(A)
The enrollee in writing, or through email or respective electronic portals, of the additional information needed to make the determination; and
(B)
The provider or healthcare facility through email or respective electronic portals of the additional information needed to make the determination;
(5)
Utilization review agents shall maintain and make available a written description of the appeal procedure by which the enrollee or the provider of record may seek review of a determination by the utilization review agent. The appeal procedure shall provide for the following:
(A)
On appeal, all determinations not to certify an admission, service, or procedure as being necessary or appropriate shall be made by a physician in the same or a similar general specialty as typically manages the medical condition, procedure or treatment under discussion as mutually deemed appropriate. For mental health and chemical dependency care, the person performing the utilization review in these appeal determinations must be both licensed at the independent practice level and in an appropriate mental health or chemical dependency discipline like that of the provider seeking authorization for the care denied;
(B)
Utilization review agents shall complete the adjudication of appeals of determinations not to certify admissions, services, and procedures no later than thirty (30) days from the date the appeal is filed and the receipt of all information necessary to complete the appeal; and
(C)
When an initial determination not to certify a health care service is made prior to or during an ongoing service requiring review, and the attending physician believes that the determination warrants immediate appeal, the attending physician shall have an opportunity to appeal that determination over the telephone on an expedited basis. A representative of a hospital or other health care provider or a representative of the enrollee or covered patient may assist in an appeal. Utilization review agents shall complete the adjudication on an expedited basis. Utilization review agents shall complete the adjudication of expedited appeals within forty-eight (48) hours of the date the appeal is filed and the receipt of all information necessary to complete the appeal. Expedited appeals which do not resolve a difference of opinion may be resubmitted through the standard appeal process;
(6)
Utilization review agents shall make staff available by toll-free telephone at least forty (40) hours per week during normal business hours;
(7)
Utilization review agents shall have a telephone system capable of accepting or recording incoming telephone calls during other than normal business hours and shall respond to these calls within two (2) working days;
(8)
Utilization review agents shall comply with all applicable laws to protect the confidentiality of individual medical records;
(9)
In the event that nationally recognized standards for a specific treatment protocol do not exist to satisfy the requirements of subdivision (a)(2)(B)(i), a utilization review agent shall ensure that all adverse determinations related to the specific treatment protocol are made by a physician or psychologist. A physician shall possess a valid license to practice medicine and shall be board certified or board eligible, or trained in the similar specialty as the health care provider who typically manages the medical condition or disease, or provides the health care service. A psychologist shall possess a valid license or certificate and shall be board certified or board eligible, or trained in the similar specialty as the health care provider who typically manages the medical condition or disease, or provides the health care service;
(10)
Utilization review agents shall allow a minimum of twenty-four (24) hours after an emergency admission, service, or procedure for an enrollee or the enrollee's representative to notify the utilization review agent and request certification or continuing treatment for that condition; and
(11)
(A)
For outpatient mental health and chemical dependency care, the patient must register pursuant to the requirements of the policy or contract. After registration, the patient shall be approved for at least twelve (12) visits to a particular provider, except as otherwise provided in this section;
(B)
Initial utilization review for such outpatient mental health or chemical dependency patients shall be limited to no more than a two (2) page form to be submitted via facsimile or internet and pursuant to state and federal privacy rules, security rules, and any final rules issued pursuant to the Health Insurance Portability and Accountability Act (HIPAA). After November 1, 2005, or sooner if required by HIPAA, the form shall be restricted to a single page. After November 1, 2005, the provider may no longer fax the form but is required to use the internet to submit necessary information if the utilization review agent so requires. In the event that the utilization review agent elects to restrict the submissions to the internet, provisions must be made to fax the information in the event of computer malfunction;
(C)
After the initial utilization review, additional information or follow-up utilization review for outpatient mental health or chemical dependency patients shall be limited to no more than eighteen percent (18%) of the total number of outpatient mental health and chemical dependency patients' reviews performed by the utilization review agent for the previous calendar year adjusted for the difference of covered lives in this state for the present calendar year, or as otherwise required by the Utilization Review Accreditation Commission (URAC) or the National Committee for Quality Assurance (NCQA). The eighteen-percent limit shall not apply to utilization review applicable to at risk populations, patients seen more than two (2) visits a week and patients for which substance abuse is reported or suspected. Calls from reviews to providers for appointment follow-up calls or for the credentialing process shall also not be subject to the eighteen-percent limit;
(D)
After utilization review as provided in this subdivision (a)(11), patients shall be authorized for at least twelve (12) additional visits or as otherwise recommended by the treatment plan;
(E)
Nothing in this part shall be construed to require compliance with the final security and privacy rules of HIPAA prior to the compliance dates set by the secretary of health and human services; and
(F)
Nothing in this part shall affect the policy or contract benefits nor shall it affect the Mental Health Parity Act, compiled in §§
56-7-2601
and
56-7-2360
.
(b)
With the exception of those standards contained in subdivisions (a)(2), (4), (9), and (11), the commissioner shall exempt from the standards of this section a utilization review agent who has received accreditation by URAC or NCQA. Standards contained in subdivisions (a)(2) and (9) do not apply to a TennCare dental benefits management program or a state insurance plan set out in title 8, chapter 27. Subdivision (a)(4) does not apply to the TennCare program or a successor to the program provided for in the Medical Assistance Act of 1968, compiled in title 71, chapter 5, or to the CoverKids Act, compiled in title 71, chapter 3, part 11 or a successor program.
Amended by 2022 Tenn. Acts, ch. 664, Secs.s3, s4 eff. 1/1/2023.
Amended by 2022 Tenn. Acts, ch. 664, s 2, eff. 1/1/2023.
Acts 1992, ch. 812, § 6; 2002, ch. 799, §§ 4, 5; 2007 , ch. 287, §§ 1, 2; 2008 , ch. 812, § 1; 2011 , ch. 243, §§ 1, 2; 2014 , ch. 731, §§ 2 - 4.