2023 Tennessee Code › Title 56 - INSURANCE (§§ 56-1-101 — 56-61-125) › Chapter 7 - POLICIES AND POLICYHOLDERS 33|373 (§§ 56-7-NEW — 56-7-3722) › Part 10 - HEALTH AND ACCIDENT INSURANCE (§§ 56-7-NEW — 56-7-1019) › Section 56-7-1013 - [Effective Until 1/1/2025] Access to health carriers' payment policies - Rules - Fee Schedules

(a)
(1)
"Fee schedule" means a list of reimbursement amounts assigned to specific codes and used by a health insurance carrier pursuant to a contract between a health insurance carrier and a healthcare provider to calculate payments paid to the provider for therapies, procedures, materials, and other services delivered to enrollees.
(2)
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)
(1)
Except as otherwise provided in subdivision (g)(2), a health insurance carrier shall provide notice of and identify any change to a provider's fee schedule and the effective date of the change at least ninety (90) days prior to the effective date of the change. The notice and identification required by this subdivision (c)(1) shall be sent to a dedicated email address or as otherwise stipulated in the contract between the provider and the health insurance carrier. The provider shall submit to the health insurance carrier a dedicated email address to receive the disclosures required by this part.
(2)
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.
(3)
This subsection (c) shall not apply to changes in standard codes and guidelines developed by the American Medical Association or a similar organization.
(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.
(f)
A health insurance carrier shall:
(1)
Within ten (10) business days of receipt of a written request from a provider, deliver to the provider at the provider's dedicated email address that provider's fee schedule, free of charge, in either a partial or full version as requested by the provider, in a transferable industry standard spreadsheet, including Microsoft Excel or other comparable format; or
(2)
Provide access to the provider's fee schedule on a secure website, so that the provider may access the fee schedule at any time throughout the term of the provider's contract with the health insurance carrier. Nothing in this subdivision (f)(2) requires a health insurance carrier to provide a fee schedule through or on a website.
(g)
(1)
Except as otherwise provided in subdivision (g)(2), no health insurance carrier shall make a change or changes to a provider's fee schedule except as follows:
(A)
Up to one (1) time during a consecutive twelve-month period. After a health insurance carrier makes a change or changes to the provider's fee schedule, it is prohibited from doing so again for at least twelve (12) months following the effective date of the change or changes; or
(B)
If a health insurance carrier and a hospital agree to the change or changes in writing.
(2)
Subdivisions (c)(1) and (g)(1) do not apply to the following changes to a fee schedule:
(A)
Any change in a provider's fee schedule due to a change effected by the federal or state government to its healthcare fee schedule, if the provider and health insurance carrier have previously agreed that the provider's fee schedule is based on a percentage or some other formula of a current government healthcare fee schedule, such as Medicare;
(B)
Any change in a provider's reimbursement for drugs, immunizations, injectables, supplies, or devices if the provider and health insurance carrier or pharmacy benefits manager as defined by §
56-7-3102
have previously agreed that any reimbursement for drugs, immunizations, injectables, supplies, or devices will be based on a percentage, or some other formula, of a price index not established by the health insurance carrier, such as the average wholesale price or average sales price;
(C)
Any changes in the provider's reimbursement for drugs, immunizations, injectables, supplies, or devices if the provider and the health insurance carrier or pharmacy benefits manager as defined in §
56-7-3102
have previously agreed to any reimbursement for drugs, immunizations, injectables, supplies, or devices in accordance with §
56-7-3104
and based upon maximum allowable cost pricing as regulated by §§
56-7-3101
and
56-7-3106
;
(D)
Any change to Current Procedural Terminology (CPT) codes, Healthcare Common Procedure Coding System (HCPCS) codes, International Statistical Classification of Disease and Related Health Problems (ICD) Codes, or other coding sets recognized or used by Centers for Medicare and Medicaid Services (CMS) that a health insurance carrier utilized in creating a provider's fee schedule;
(E)
Any change to revenue codes as established by the National Uniform Billing Committee (NUBC);
(F)
Any changes in a provider's fee schedule due to one (1) or more of the following if previously agreed to in a provider's agreement with a health insurance carrier:
(i)
Payments made to the healthcare provider by the health insurance carrier or payments made to the health insurance carrier by the provider that are based on values or quality measures explicitly described in the written agreement between the provider and the health insurance carrier intended to improve care provided to the health insurance carrier's members;
(ii)
Escalator or de-escalator clauses;
(iii)
Provisions that require adjustments to payment due to population health management performance or results; or
(iv)
Any arrangements, initiatives, or value-based payments relating to or resulting from the implementation or operation of the Tennessee Health Care Innovation Initiative or any successor state program applicable to provider agreements covered by this section.
(h)
Notwithstanding any law to the contrary, including other provisions of this section, nothing in this section applies to:
(1)
An enrollee's benefit package, or coverage terms and conditions, unrelated to application of fee schedules and reimbursements, including, but not limited to, provisions regarding eligibility for coverage, deductibles and copayments, coordination of benefits, and coverage limitations and exclusions;
(2)
An entity that is subject to delinquency proceedings and for which the commissioner of commerce and insurance has been appointed receiver, or an entity placed under administrative supervision by order of the commissioner pursuant to the Insurers Rehabilitation and Liquidation Act, compiled in chapter 9 of this title;
(3)
A contract amendment that is made due to a change in federal or state law;
(4)
A contract between a health insurance carrier and a healthcare provider for items or services to be provided for individuals covered by any Medicare Advantage, Medicare Select, Medicare Supplement, Medicare and Medicaid Enrollees (MME), Medicare Dual Special Needs, and Medicare Private Fee for Service; or the state, local government, and local education insurance plans established under title 8, chapter 27; or
(5)
The TennCare program or any successor Medicaid program provided for in title 71, chapter 5; the CoverKids Act of 2006, compiled in title 71, chapter 3, part 11; the Access Tennessee Act of 2006, compiled in part 29 of this chapter; any other plan managed by the health care finance administration division of the department of finance and administration or any successor division or department; or the group insurance plans offered under title 8, chapter 27.
Amended by 2017 Tenn. Acts, ch. 88, Secs.s 3, s 4 eff. 1/1/2019.
Amended by 2017 Tenn. Acts, ch. 88, s 2, eff. 1/1/2019.
Acts 2002, ch. 638, §§ 1, 2; 2008 , ch. 987, § 1; 2009 , ch. 333, § 1.
This section is set out more than once due to postponed, multiple, or conflicting amendments.