Tennessee Prior Authorization Rules

Overview

Tennessee Code Annotated Section 56-7-1901 et seq. governs prior authorization in health plans. Insurers must respond to standard prior authorization requests within 3 business days and to expedited requests within 1 business day of receiving complete clinical information. Denial notices must include the specific clinical criteria that were not met and the clinical rationale supporting the denial.

Key Requirements

1. Standard PA Timeline: Three business days from receipt of complete clinical information to approve, deny, or request additional information.
2. Expedited/Urgent PA Timeline: One business day for expedited requests where a standard timeline would adversely affect the patient's health.
3. Emergency Services Exception: Prior authorization is not required for emergency services. Retrospective review is permitted only within 30 days of service.
4. Denial Rationale Requirements: Denial notices must include the specific clinical criteria relied upon and the evidence-based or clinical rationale for the denial.
5. Care During Appeal: Providers may proceed with treatment pending appeal if the delay would cause harm to the patient, and the insurer must reimburse if the appeal results in approval.

Penalties and Enforcement

The Tennessee Department of Commerce and Insurance enforces prior authorization requirements. Violations include failing to meet response deadlines, issuing denials without adequate clinical rationale, and refusing to allow internal or external appeals. Violators are subject to complaints, market conduct examinations, and civil penalties.

Appeals and Exceptions

Patients and providers have the right to appeal any prior authorization denial. Internal appeal requests must be submitted within 180 days of the denial and are typically decided within 30 days. For urgent situations, expedited internal appeals are decided within 3 business days. External review through the Tennessee Department of Commerce and Insurance is available if the internal appeal is denied. Exceptions to the PA requirement are limited to emergency services.

Interaction with Federal Law

Federal regulations under CMS-0057-F beginning 2026-2027 establish federal prior authorization response timeframes that complement Tennessee state law. These federal rules do not preempt Tennessee law; whichever provides the stronger protection applies. Self-funded ERISA plans follow federal requirements, while state-regulated plans must meet both state and federal standards.

Common Questions