Tennessee § 56-6-704 - Utilization review agents.

§ 56-6-704. Utilization review agents.

Utilization review agents shall adhere to the minimum standards set forth in § 56-6-705. Utilization review programs for the mental health and chemical dependency care must comply with the most recent requirements of nationally recognized utilization review accrediting bodies, i.e., the utilization review accreditation commission (URAC) and the national committee for quality assurance (NCQA), if the agent is accredited and with all final security and privacy rules on protected health information as defined in the Health Insurance Portability and Accountability Act (HIPAA). However, 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. A utilization review agent may not conduct utilization review in this state unless the utilization review agent has certified to the commissioner in writing that the agent is in compliance with § 56-6-705. Certification shall be made annually on or before July 1 of each calendar year. In addition, a utilization review agent shall file the following information: The name, address, telephone number, and normal business hours of the utilization review agent; The name and telephone number of a person for the commissioner to contact; A description of the appeal procedures for utilization review determinations; and Utilization review programs for mental health and chemical dependency care shall make available to a provider submitting patient utilization review information a description of utilization review standards and procedures applicable to that provider. Any material changes in the information filed in accordance with this section shall be filed with the commissioner within thirty (30) days of the change. Upon filing the certification, each utilization review agent shall pay an annual fee in the amount of one thousand dollars ($1,000) to the department. The commissioner shall exempt from payment of the annual fee any utilization review agent that has received accreditation by URAC or NCQA. All fees paid to the department under this part shall be held by the commissioner as expendable receipts for the purpose of administering this part. Acts 1992, ch. 812, § 5; 1993, ch. 482, § 1; 2002, ch. 799, §§ 2, 3; 2009, ch. 611, §§ 1, 2. Compiler's Notes. Acts 2002, ch. 799, § 6 provided that nothing in the act shall apply to the TennCare Program. The federal Health Insurance Portability and Accountability Act of 1996 is codified primarily in U.S.C. title 42. Cross-References. Health insurance portability, availability, and renewability, title 56, ch. 7, part 28. Attorney General Opinions. Due to the definition of utilization review agent, when utilization review is performed pertaining to an health maintenance organization (HMO) enrollee by the enrollee's HMO, such HMO is not covered by Chapter 799 of the Public Acts of 2002, and the requirements of T.C.A. § 56-6-701 et seq., OAG 02-127, 2002 Tenn. AG LEXIS 132 (11/25/02).