2016 Tennessee Code
Title 56 - Insurance
Chapter 7 - Policies and Policyholders
Part 1 - General Provisions
§ 56-7-120. Assignment of benefits to health care provider.

(a) (1) Notwithstanding any law, rule, or regulation to the contrary, whenever any policy of insurance issued in this state provides for coverage of health care rendered by a provider covered under title 63, the insured or other persons entitled to benefits under the policy shall be entitled to assign these benefits to the healthcare provider and such rights must be stated clearly in the policy. Notice of the assignment must be in writing to the insurer in order to be effective; provided, however, such notice can be provided by other means if it is so stated in the policy.

(2) If a property and casualty insurance policy includes a specified medical expense benefit payable without regard to fault, but does not permit assignment of the benefit, the insurer must establish a process that, when requested by the insured, the insurer shall disburse funds in the names of the insured and the health care provider as joint payees. Disbursement shall be subject to terms and conditions under the issued insurance policy.

(b) As used in this section, "health care provider" means a doctor of medicine, osteopathy, dentistry, chiropractic, podiatry or optometry, a pharmacist or pharmacy, a hospital, home health agency, an entity providing infusion therapy services or an entity providing medical equipment services.

(c) (1) For purposes of this subsection (c):

(A) "Participating healthcare facility" means a healthcare facility that has a current contract provider agreement with the insured's insurer; and

(B) "Nonparticipating facility-based physician" means a physician:

(i) To whom a participating healthcare facility has granted clinical privileges;

(ii) Who provides services to patients of the participating healthcare facility pursuant to those clinical privileges; and

(iii) Who does not have a current contract provider agreement with the insured's insurer.

(2) An insured's assignment of benefits, pursuant to subsection (a), may be disregarded by an insurer if:

(A) The assignment of benefits is to a nonparticipating facility-based physician; and

(B) All of the following conditions are not satisfied:

(i) (a) The healthcare facility provides written notice to the insured that informs the insured that:

(1) The nonparticipating facility-based physician may not have a current contract provider agreement with the insured's insurer; and

(2) The insured may receive a bill for medical services from the nonparticipating facility-based physician for the amount unpaid by the insured's insurer;

(b) The notice required by subdivision (c)(2)(B)(i)(a) shall be provided to the insured, or the insured's personal representative, prior to when the insured first receives services from the nonparticipating facility-based physician. In circumstances where the insured is receiving medical services through a hospital emergency department or is incapacitated or unconscious at the time of receiving such services, the notice will not be required. The failure of the healthcare facility to provide the notice required by subdivision (c)(2)(B)(i)(a) shall not give rise to any right of indemnification or private cause of action against the healthcare facility by any nonparticipating facility-based physician for an insurer's disregard of an insured's assignment of benefits unless the healthcare facility's failure to provide such notice is due to willful or wanton misconduct of an agent of the healthcare facility; and

(ii) The nonparticipating facility-based physician provides the insured a billing statement that:

(a) Contains an itemized listing of the services and supplies provided along with the dates when the services and supplies were provided;

(b) Contains a conspicuous, plain language explanation that:

(1) The nonparticipating facility-based physician does not have a current contract provider agreement with the insured's insurer; and

(2) The insurer has paid a rate, as determined by the insurer, that is below the nonparticipating facility-based physician's billed amount;

(c) Contains a telephone number to call to discuss the billing statement, provide an explanation of any acronyms, abbreviations, and numbers used on the statement, or discuss any payment issues;

(d) Contains a statement that the insured may call to discuss alternative payment arrangements; and

(e) For billing statements that total an amount greater than two hundred dollars ($200), over any applicable copayments, coinsurance or deductibles, states, in plain language, that if the insured finalizes a payment plan agreement within forty-five (45) days of receiving the first billing statement and substantially complies with the agreement, the nonparticipating facility-based physician shall not furnish adverse information to a consumer reporting agency regarding an amount owed by the insured. For purposes of this subdivision (c)(2)(B)(ii)(e), a patient shall be considered out of substantial compliance with the payment plan agreement if the payments are not made in compliance with the agreement for a period of forty-five (45) days.

(3) Nothing in this subsection (c) shall apply to accident-only, specified disease, hospital indemnity, Medicare supplement, long-term care or other limited benefit hospital insurance policies.