2010 Tennessee Code
Title 56 - Insurance
Chapter 7 - Policies and Policyholders
Part 10 - Health and Accident Insurance
56-7-1013 - Access to health carriers' payment policies Rules Fee Schedules.

56-7-1013. Access to health carriers' payment policies Rules Fee Schedules.

(a)  As used in this section, “health insurance carrier” means any entity subject to the insurance laws and regulations of this state, or subject to the jurisdiction of the commissioner of commerce and insurance, that contracts with healthcare providers in connection with a plan of health insurance, health benefits or health services.

(b)  Health insurance carriers shall provide or make available to a healthcare provider, when contracting or renewing an existing contract with the provider, the payment or fee schedules or other information sufficient to enable the healthcare provider to determine the manner and amount of payments under the contract for the healthcare provider's services prior to final execution or renewal of the contract. The payment or fee schedule or other information submitted to a healthcare provider pursuant to this section shall include a description of processes and factors that may be applicable and that may affect actual payment, e.g., copayments, coinsurance, deductibles, risk sharing arrangements and liability of third parties. A health insurance carrier, upon request of a healthcare provider, shall make available to the healthcare provider examples of actual payment for procedures frequently performed by the provider that involve combinations of services or payment codes, if the actual payment for the procedures can not be ascertained from the fee schedule or other information submitted to a healthcare provider pursuant to this section. The provisions of this subsection (b) requiring the submission of a fee schedule or other information upon renewal of an existing contract shall not be applicable to renewal of an existing contract when the payment or fee schedule previously provided to the healthcare provider has not changed.

(c)  Any change to payment or fee schedules applicable to providers under contract with a health insurance carrier shall be made available to the providers at least thirty (30) days prior to the effective date of the amendment; provided, that this subsection (c) shall not apply to changes in standard codes and guidelines developed by the American Medical Association or a similar organization. A health insurance carrier shall not require any hospital, by contract, reimbursement or otherwise, to notify the health insurance carrier of a hospital inpatient admission within less than one (1) business day of the hospital inpatient admission if the notification or admission occurs on a weekend or federal holiday. Nothing in this subsection (c) shall affect the applicability or administration of other provisions of a contract between a hospital and health insurance carrier, including, without limitation, preauthorization requirements for scheduled inpatient admissions.

(d)  A healthcare provider receiving information pursuant to subsection (b) shall not share the information with an unrelated person without the prior written consent of the health insurance carrier. The remedies available to a health insurance carrier to enforce this subsection (d) shall include, but not be limited to, injunctive relief. A health insurance carrier seeking extraordinary relief to enforce this subsection (d) shall not be required to establish irreparable harm with regard to the sharing of competitively sensitive information.

(e)  This section shall not apply to nonprofit dental service corporations established under chapter 30 of this title.

[Acts 2002, ch. 638, §§ 1, 2; 2008, ch. 987, § 1; 2009, ch. 333, § 1.]