Section 1200-13-16-.04 - PRIOR AUTHORIZATION AND CONCURRENT UTILIZATION REVIEW(1) The Bureau of TennCare may identify certain items or services that, for purposes of determining medical necessity, shall require prior authorization and/or concurrent review. (a) Managed care contractors and/or a state agency performing the function of a managed care contractor shall implement prior authorization and/or concurrent review procedures for all items or services specified by the Bureau of TennCare and, at their individual discretion, may require prior authorization and/or concurrent review for additional non-emergency medical items or services not specified by the Bureau of TennCare.(b) Managed care contractors and/or a state agency performing the function of a managed care contractor will inform their enrollees and their participating providers which medical items or services require prior authorization and/or concurrent review. Such notice need not be individualized in nature. Thus, failure to provide individualized prior authorization notices does not invalidate the requirement for prior authorization and/or concurrent review. Notice to providers shall be in writing and such notice requirement may be satisfied by publishing notice on the internet.Tenn. Comp. R. & Regs. 1200-13-16-.04
Public necessity rule filed December 1, 2006; expires May 15, 2007. Original rule filed March 1, 2007; effective May 15, 2007.Authority: T.C.A. §§ 4-5-209, 71-5-105, 71-5-109, Executive Order No. 23.