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:

External Review Organizations Application Packet

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:

External Review Organizations Application Packet (Renewal)

Agency Fee:

$500 for accredited entities and $1,500 for unaccredited entities.

Due:

Biennially by the registration anniversary date.

Tennessee Utilization Review Organization Registration

Type of Review:

Workers' Compensation

Agency:Tennessee Department of Labor & Workforce - Bureau of Workers' Compensation
Law:

TN Admin Code 0800-02-06-.02

Foreign Qualification is Prerequisite:No
Registered Agent (Special Agency) Required?No

Initial Registration

Form:

Form C-39: Provider Registration for Utilization Review

Agency Fee:

$0

Required Attachments:
  • A copy of the “Approved” certification letter, issued by the Tennessee Department of Commerce and Insurance
  • Proof of all certifications listed on the application

Renewal Not Required

Not required



Tennessee Utilization Review Registration

Type of Review:

Medical Utilization Review

Agency:Tennessee Department of Commerce and Insurance
Law:

TN Code § 56-6-704 

Initial Registration

Form:

Utilization Review Application Packet

Agency Fee:

$1,000

Registration Renewal

Form:

Utilization Review Application Packet (Renewal)

Agency Fee:

$1,000

Due:

Annually by July 1.

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.

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