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 d 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 r 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 des, 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.
Tennessee Legal Code