Section 56-7-3703 - [Effective 1/1/2025] Requirements for initial adverse determinations(a) If a utilization review organization makes an adverse determination for a prior authorization of a healthcare service, then the carrier or organization shall include the following in the notification to the enrollee and the enrollee's healthcare provider requesting the prior authorization on the enrollee's behalf: (1) The reasons for the adverse determination and, if applicable, related evidence-based criteria, including a description of missing or insufficient documentation or lack of coverage of the enrollee for the healthcare service;(2) The right to appeal the adverse determination;(3) Instructions on how to file the appeal; and(4) Additional documentation necessary to support the appeal.(b) An adverse determination regarding a request for prior authorization for a healthcare service must be made by a licensed physician or a healthcare professional with the same or a similar specialty as the healthcare professional requesting the prior authorization.(c) This section does not apply to an initial adverse determination for prescription drugs that are covered under an enrollee's benefit plan.Amended by 2023 Tenn. Acts, ch. 395, s 4, eff. 1/1/2025.