2010 Tennessee Code
Title 56 - Insurance
Chapter 60 - Preferred Provider Organization Transparency Act [Effective January 1, 2010]
56-60-105 - Granting a third party access to a provider's health care services and contractual discounts pursuant to a provider network contract. [Effective January 1, 2010.]

56-60-105. Granting a third party access to a provider's health care services and contractual discounts pursuant to a provider network contract. [Effective January 1, 2010.]

(a)  A contracting entity shall only grant access to a provider's health care services and contractual discounts pursuant to the contracting entity's provider network contract if:

     (1)  The provider network contract clearly and plainly authorizes the contracting entity to enter into an agreement with a third party allowing the third party to exercise the contracting entity's rights and responsibilities under the provider network contract as if the third party were the contracting entity; and

     (2)  The third party accessing a provider's services and contractual discounts pursuant to the provider network contract is contractually obligated to comply with all applicable terms, limitations and conditions of the provider network contract.

(b)  A contracting entity that grants a third party access to a provider's health care services and contractual discounts pursuant to a provider network contract shall:

     (1)  Identify and supply to a provider, upon request at the time a provider network contract is entered into with the provider, a written or electronic list of all third parties known at the time of contracting to which the contracting entity has or will grant access to the provider's health care services and contractual discounts pursuant to the provider network contract;

     (2)  Maintain an Internet web site or a toll-free telephone number through which a provider may obtain a listing, updated at least quarterly, of the third parties to which the contracting entity or another third party has executed contracts to grant access to the provider's health care services and contractual discounts pursuant to the provider network contract;

     (3)  Provide each third party who contracts with the contracting entity to gain access to the provider network contract a summary of the contracting entity's current standard provider contract terms;

     (4)  Require that each third party who contracts with the contracting entity to gain access to the provider network contract:

          (A)  Designate an individual or department responsible for responding to provider inquiries concerning the third party's access to the provider network contract; and

          (B)  Include the following information on each remittance advice (RA), explanation of payment (EOP) or other similar documentation furnished to a provider when a contractual discount is exercised pursuant to the contracting entity's provider network contract:

                (i)  The source of the contractual discount taken by the third party; and

                (ii)  A direct toll-free telephone number answerable Monday through Friday during normal business hours for the individual or department designated to be responsible for responding to provider inquiries pursuant to subdivision (b)(4)(A); and

     (5)  (A)  Notify any third party who contracts with the contracting entity to gain access to a provider's services and contractual discounts pursuant to the provider network contract of the termination of the provider network contract within thirty (30) calendar days of the contracting entity's receipt of notification of the termination;

          (B)  The notice required by subdivision (b)(5)(A) shall be provided through written notice, electronic communication or an update to an electronic database of provider listings.

(c)  Subject to any applicable continuity of care requirements, provisions of the provider network contract or contrary law:

     (1)  A third party's right to access a provider's health care services and contractual discounts pursuant to a provider network contract shall terminate on the date the provider network contract is terminated;

     (2)  Claims for health care services performed after the termination date of the provider network contract are not eligible for processing and payment in accordance with the provider network contract; and

     (3)  Claims for health care services performed before the termination date of the provider network contract, but processed after the termination date, are eligible for processing and payment in accordance with the provider network contract.

(d)  (1)  All information made available to a provider in accordance with the requirements of this chapter shall be confidential and shall not be disclosed to any individual or entity not involved in the provider's practice or the administration of such practice without the prior written consent of the contracting entity.

     (2)  A contracting entity may reference or include within the contract or a related document the language contained in subdivision (d)(1), or language that is substantially similar in scope and purpose, in order to affirm each party's knowledge of and agreement to comply with the confidentiality provision.

     (3)  This subsection (d) shall not preclude the information being disclosed for purposes of dispute resolution, enforcement of this chapter or assistance in enforcing this chapter.

[Acts 2009, ch. 466, § 6.]