What is prior authorization?
Prior authorization (PA) means the health plan must approve certain care before it will cover it. Providers often submit requests for you, but you still have rights if PA is denied or delayed.
Overview: Prior authorizations. Tennessee-only details below.
Confirm plan type: Tennessee: Start Here.
Tennessee PA rules
Tennessee's Prior Authorization Fairness Act (Tenn. Code Ann. §§ 56-7-3701–3722, Public Chapter 395 of 2023, effective January 1, 2025) applies to most fully insured commercial health plans regulated by TDCI. It generally does not apply to Medicare, typical self-funded ERISA plans, TennCare, or CoverKids (§ 56-7-3720).
Deemed approval deadlines (§ 56-7-3705)
- Non-urgent PA: deemed approved if the carrier or UR organization fails to approve, deny, or request needed information within 7 calendar days of submission
- Overall cap: the full PA process (including supplemental information) must not exceed 17 calendar days unless an exception applies
- Urgent PA: deemed approved if no decision or information request within 72 hours, plus one additional business day when applicable; provider must respond to supplemental requests within the same window
Other protections
- Electronic PA: carriers must accept electronic PA using NCPDP SCRIPT standards where applicable (§ 56-7-3708)
- MAT / opioid use disorder: categorical ban on PA for FDA-labeled medications for opioid use disorder (§ 56-7-3710)
- PA duration: default 6-month validity; 6-month validity for chronic conditions; 90-day continuity when switching plans mid-year
- Transparency: 60/45-day advance notice before new PA requirements; annual public PA approval/denial statistics by service code (§ 56-7-3717)
- Step therapy: Tennessee enacted a separate step-therapy exception law (2022); exceptions must be considered when clinically appropriate
Pending reform (SB 1261, 2026 session)
Legislation introduced in 2026 would restrict insurers and UR vendors from using AI or algorithms to make final medical necessity determinations without physician review. As of mid-2026, check current bill status before relying on it.
Where to look up PA rules
Check your plan materials and the carrier's provider or member portal first.
Carrier links: Tennessee prior auth & internal appeals links.
Medicaid
TennCare pharmacy PA must meet federal Medicaid timing (often 24-hour response; 72-hour emergency supply when applicable under 42 U.S.C. § 1396r-8). Medical benefit denials use the TennCare appeal process—not commercial PA Fairness Act rules.
If PA is denied
Appeal the adverse determination using your plan's internal grievance process under Ch. 56-61, then external review if needed.
Next: Tennessee internal appeals.
Urgent care
Mark PA requests urgent when delay would seriously jeopardize life or health. Under the PA Fairness Act, failure to act within 72 hours (+1 business day when applicable) can result in deemed approval.
You may also request expedited internal and external appeals under Ch. 56-61 in qualifying urgent situations.