2023 Tennessee Code › Title 56 - INSURANCE (§§ 56-1-101 — 56-61-125) › Chapter 7 - POLICIES AND POLICYHOLDERS 33|373 (§§ 56-7-NEW — 56-7-3722) › Part 37 - PRIOR AUTHORIZATION FAIRNESS ACT (§§ 56-7-3701 — 56-7-3722) › Section 56-7-3702 - [Effective 1/1/2025] Part definitions

As used in this part:
(1)
"Additional business day" means the first weekday not designated as a state or federal holiday;
(2)
"Adverse determination" has the same meaning as defined in §
56-61-102
;
(3)
"Chronic condition" means a condition that has an expected duration of one (1) year or more and requires ongoing medical attention or limits activities of daily living, or both;
(4)
"Commissioner" has the same meaning as defined in §
56-1-102
;
(5)
"Emergency healthcare services" means emergency services as defined in §
56-7-2355
;
(6)
"Enrollee" has the same meaning as defined in §
56-6-703
;
(7)
"Enrollee benefit plan" means the right to have a payment made by a health carrier for a prescription drug listed on the applicable formulary or healthcare services in accordance with coverage contained within a health benefit plan delivered, issued for delivery, or renewed in this state;
(8)
"Facility" means an institution licensed under title 33 or 68;
(9)
"Health carrier" has the same meaning as defined in §
56-61-102
;
(10)
"Healthcare prescriber" means a prescriber as defined in §
53-10-203
;
(11)
"Healthcare professional" has the same meaning as defined in §
56-61-102
;
(12)
"Healthcare provider" has the same meaning as defined in §
56-61-102
;
(13)
"Healthcare service" means a service rendered by a healthcare provider or at a practice that provides testing, monitoring, diagnosis, or treatment of a human disease or condition, or dispenses medical devices, medical appliances, or medical goods for the treatment of a human disease or condition;
(14)
"Inpatient service" means care provided in a hospital or other type of inpatient facility where an individual is admitted and spends one (1) or more nights, depending on the individual's medical condition;
(15)
"Medically necessary" or "medical necessity" has the same meaning as defined in §
56-61-102
;
(16)
"Physician" means a medical doctor or osteopathic physician with a valid state medical license issued pursuant to title 63, chapter 6 or 9;
(17)
"Practice" means an entity formed with at least one (1) healthcare provider to provide healthcare services;
(18)
"Prescription drug" has the same meaning as defined in §
56-7-3201
;
(19)
"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;
(20)
"Urgent care request" has the same meaning as defined in §
56-61-102
; and
(21)
"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; and
(B)
A health maintenance organization, or another individual or entity that provides, offers to provide, or administers hospital, outpatient, medical, behavioral health, prescription drug, or other health benefits to a person treated by a healthcare provider in this state under a health insurance policy, plan, or contract.
Amended by 2023 Tenn. Acts, ch. 395, s 4, eff. 1/1/2025.