Utilization Review Licensing in Tennessee
Utilization review licenses and certificates are typically issued for organizations conducting either medical or workers’ compensation reviews. This guide contains information about utilization review in Tennessee. For assistance with licensing, please contact us to learn about our software and managed license services.
Tennessee External Review Registration
| Type of Review: | Medical Utilization Review |
| Agency: | Tennessee Department of Commerce and Insurance |
| Law: | TN Code § 56-61-120 |
| Registered Agent (Special Agency) Required? | Yes |
Initial Registration
| Form: | |
| Agency Fee: | $500 for accredited entities and $1,500 for unaccredited entities. |
| Required Attachments: | See the application form for a detailed list of attachments. |
Registration Renewal
| Form: | |
| Agency Fee: | $500 for accredited entities and $1,500 for unaccredited entities. |
| Due: | Biennially by the registration anniversary date. |
Tennessee Utilization Review Organization Registration
Initial Registration
| Form: | |
| Agency Fee: | $0 |
| Required Attachments: |
|
Renewal Not Required
Not required
Tennessee Resources
Adverse Determination - When a health care plan or utilization review program decides that a medical treatment or service is not necessary.
Concurrent Review - Utilization review that is conducted during a patient’s course of treatment.
External Review - When an independent review organization is consulted to appeal an insurance company’s adverse determination.
Independent Review Organization (IRO) - Unbiased third-parties that conduct utilization review.
Prospective Review - Utilization review that occurs prior to treatment.
Retrospective Review - Utilization review that occurs after treatment and often after payment.
Utilization Review - A system for evaluating the medical necessity, efficiency, and appropriateness of medical services.
Utilization Review Agent (URA) - An entity that conducts utilization review.
Utilization Review Plan - A document of the procedures used during utilization review.
