reglab/statecodes huggingface dataset:
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 31 - PHARMACY BENEFITS MANAGERS (§§ 56-7-3101 — 56-7-3123) › Section 56-7-3115 - Prohibited charges

A covered entity or pharmacy benefits manager shall not charge a pharmacist or a pharmacy a fee related to a claim unless it is apparent at the time of claim processing and is reported on the remittance advice of an adjudicated claim. This section does not prohibit a covered entity or pharmacy benefits manager from entering into an agreement with a pharmacy or pharmacist which includes prospective performance-based incentives and increases payment to pharmacies or pharmacists.
Added by 2019 Tenn. Acts, ch. 470,s 4, eff. 7/1/2019.
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 31 - PHARMACY BENEFITS MANAGERS (§§ 56-7-3101 — 56-7-3123) › Section 56-7-3116 - Prohibited terms or conditions in contracts

A covered entity or pharmacy benefits manager shall not include any term or condition in a contract with a pharmacy or pharmacist that requires a pharmacist to dispense a drug or other product to a patient contrary to a pharmacist's professional judgment.
Added by 2019 Tenn. Acts, ch. 470,s 4, eff. 7/1/2019.
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 31 - PHARMACY BENEFITS MANAGERS (§§ 56-7-3101 — 56-7-3123) › Section 56-7-3117 - Disclosure of material changes to contract provisions

A covered entity or pharmacy benefits manager shall disclose to a pharmacy or pharmacist in its network, at least thirty (30) days before the date the change becomes effective, any material change to a contract provision that affects the terms of reimbursement, the process for verifying benefits and eligibility, the dispute resolution procedure, the procedure for verifying drugs included in the formulary, and the procedure for contract termination. Nothing in this section prohibits a covered entity or pharmacy benefits manager from taking action without notice against a pharmacy or pharmacist in its network for a fraudulent claim or service.
Added by 2019 Tenn. Acts, ch. 470,s 4, eff. 7/1/2019.
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 31 - PHARMACY BENEFITS MANAGERS (§§ 56-7-3101 — 56-7-3123) › Section 56-7-3118 - Mutual agreement on terms and conditions for provision of pharmacy services - Use of untrue, deceptive, or misleading advertisement, etc. prohibited - Effect of removal of pharmacist or pharmacy - Pattern or practice of reimbursing pharmacies or pharmacists lesser amount prohibited

(a)
Each contract between a covered entity or pharmacy benefits manager and a pharmacist or pharmacy must be mutually agreed upon and must outline the terms and conditions for the provision of pharmacy services.
(b)
A covered entity or pharmacy benefits manager shall not cause or knowingly permit the use of any advertisement, promotion, solicitation, representation, proposal, or offer that is untrue, deceptive, or misleading.
(c)
Removal of a pharmacy or a pharmacist from the network of a covered entity or pharmacy benefits manager does not release the covered entity or pharmacy benefits manager from the obligation to make any payment due to the pharmacy or pharmacist for services that have been properly rendered prior to the pharmacy being removed from the network. Properly rendered services do not include any services related to a fraudulent claim or intentional misrepresentation.
(d)
A covered entity or pharmacy benefits manager shall not engage in a pattern or practice of reimbursing pharmacies or pharmacists in this state less than the amount that the pharmacy benefits manager reimburses a pharmacy benefits manager affiliate for providing the same drug or dispensed product or service.
Added by 2019 Tenn. Acts, ch. 470,s 4, eff. 7/1/2019.
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 31 - PHARMACY BENEFITS MANAGERS (§§ 56-7-3101 — 56-7-3123) › Section 56-7-3119 - Dealings with 340B entities - Discrimination against 340B entity prohibited

(a)
A health insurance issuer, managed health insurance issuer as defined in §
56-32-128(a)
, pharmacy benefits manager, or other third-party payer shall not:
(1)
Reimburse a 340B entity for pharmacy-dispensed drugs at a rate lower than the rate paid for the same drug by national drug code number to pharmacies that are not 340B entities;
(2)
Assess a fee, chargeback, or adjustment upon a 340B entity that is not equally assessed on non-340B entities;
(3)
Exclude 340B entities from its network of participating pharmacies based on criteria that is not applied to non-340B entities; or
(4)
Require a claim for a drug by national drug code number to include a modifier to identify that the drug is a 340B drug.
(b)
With respect to a patient eligible to receive drugs subject to an agreement under
42 U.S.C. § 256b
, a pharmacy benefits manager, or third party that makes payment for those drugs, shall not discriminate against a 340B entity in a manner that violates §
56-7-2359
or otherwise prevents or interferes with the patient's choice to receive those drugs from the 340B entity.
(c)
Notwithstanding §
56-7-1005
, this section does not apply to:
(1)
The TennCare program administered under the Medical Assistance Act of 1968, compiled in title 71, chapter 5, part 1, or a successor Medicaid program;
(2)
The CoverKids Act of 2006, compiled in title 71, chapter 3, part 11, or a successor program; or
(3)
The prescription drug program described in chapter 57 of this title, or a successor program.
(d)
As used in this section:
(1)
"340B entity" means a covered entity participating in the federal 340B drug discount program, as defined in section 340B of the Public Health Service Act,
42 U.S.C. § 256b
, including the entity's pharmacy or pharmacies, or any pharmacy or pharmacies under contract with the 340B covered entity to dispense drugs on behalf of the 340B covered entity; and
(2)
"National drug code number" means the unique national drug code number that identifies a specific approved drug, its manufacturer, and its package presentation.
Added by 2021 Tenn. Acts, ch. 569, s 1, eff. 7/1/2021.
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 31 - PHARMACY BENEFITS MANAGERS (§§ 56-7-3101 — 56-7-3123) › Section 56-7-3120 - Penalty for obtaining prescription drugs from contracted pharmacy prohibited - Interference with patient's right to choose contracted pharmacy or contracted provider of choice prohibited

(a)
A pharmacy benefits manager or a covered entity shall not require a person covered under a pharmacy benefit contract, that provides coverage for prescription drugs, including specialty drugs, to pay an additional fee, higher copay, higher coinsurance, second copay, second coinsurance, or other penalty when obtaining prescription drugs, including specialty drugs from a contracted pharmacy.
(b)
A pharmacy benefits manager or a covered entity shall not:
(1)
Interfere with the right of a patient, participant, or beneficiary to choose a contracted pharmacy or contracted provider of choice in a manner that violates §
56-7-2359
; or
(2)
Offer financial or other incentives to a patient, participant, or beneficiary to persuade the patient, participant, or beneficiary to utilize a pharmacy owned by or financially beneficial to the pharmacy benefits manager or covered entity.
Amended by 2022 Tenn. Acts, ch. 1070, s 5, eff. 1/1/2023.
Added by 2021 Tenn. Acts, ch. 569, s 2, eff. 7/1/2021.
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 31 - PHARMACY BENEFITS MANAGERS (§§ 56-7-3101 — 56-7-3123) › Section 56-7-3121 - Utilization of any pharmacy in state - Preferred network of pharmacies and nonpreferred network of pharmacies

(a)
A pharmacy benefits manager shall allow patients, participants, and beneficiaries of the pharmacy benefits plans and programs that the pharmacy benefits manager serves to utilize any pharmacy within this state that is licensed to dispense the prescription pharmaceutical product that the patient, participant, or beneficiary seeks to fill, as long as the pharmacy is willing to accept the same terms and conditions that the pharmacy benefits manager has established for at least one (1) of the networks of pharmacies that the pharmacy benefits manager has established to serve patients, participants, and beneficiaries within this state.
(b)
A pharmacy benefits manager may establish a preferred network of pharmacies and a non-preferred network of pharmacies. The pharmacy benefits manager shall not prohibit a pharmacy from participating in either type of network within this state as long as the pharmacy is licensed by this state and the federal government and willing to accept the same terms and conditions that the pharmacy benefits manager has established for other pharmacies participating within the network that the pharmacy wishes to join.
(c)
A pharmacy benefits manager shall not charge a patient, participant, or beneficiary of a pharmacy benefits plan or program that the pharmacy benefits manager serves a different copayment obligation or additional fee, or provide any inducement or financial incentive, for using any pharmacy within a given network of pharmacies established by the pharmacy benefits manager to serve patients, participants, and beneficiaries within this state.
Acts 2022, ch. 1070, § 6.
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 31 - PHARMACY BENEFITS MANAGERS (§§ 56-7-3101 — 56-7-3123) › Section 56-7-3122 - Applicability of part

Notwithstanding another law, this part applies to plans governed by the Employee Retirement Income Security Act of 1974 (ERISA) (
29 U.S.C. § 1001
et seq.).
Added by 2022 Tenn. Acts, ch. 1070, s 7, eff. 1/1/2023.
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 31 - PHARMACY BENEFITS MANAGERS (§§ 56-7-3101 — 56-7-3123) › Section 56-7-3123 - Confidentiality of information obtained or produced pursuant to audit - Disclosure of audit findings

(a)
Except as provided in subsection (b), any information obtained or produced by the department pursuant to an audit of a pharmacy benefits manager is confidential, is not a public record subject to disclosure, and is exempt from title 10, chapter 7.
(b)
Audit findings by the department based upon a completed audit of a pharmacy benefits manager are public records subject to public disclosure by the department.
Added by 2022 Tenn. Acts, ch. 1070,s 9, eff. 1/1/2023.
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 32 - PHARMACY BENEFITS (§§ 56-7-3201 — 56-7-3210) › Section 56-7-3201 - Part definitions

As used in this part, unless the context otherwise requires:
(1)
"Actual reimbursement" means the total amount that a covered entity or pharmacy benefits manager determines that a pharmacy or other dispenser will receive consistent with the provider agreement, and is the sum of the amount the covered entity or pharmacy benefits manager will pay directly to the pharmacy or other dispenser plus any applicable patient out-of-pocket cost paid directly by the patient to the pharmacy or other dispenser, for dispensing of a particular prescription or providing a covered service;
(2)
"Cost sharing requirement" means a copayment, coinsurance, deductible, or annual limitation on cost sharing, including, but not limited to, a limitation subject to
42 U.S.C. §§ 18022(c)
and
300gg-6(b)
, required by, or on behalf of, an enrollee in order to receive a specific healthcare service covered by a health plan, including a prescription drug, whether under the medical or the pharmacy benefit;
(3)
"Covered entity" means a covered entity as defined in §
56-7-3102
;
(4)
"Generic alternative" means a drug that is designated to be therapeutically equivalent by the United States food and drug administration's Approved Drug Products with Therapeutic Equivalence Evaluations;
(5)
"Pharmacy benefits manager" means a pharmacy benefits manager as defined in §
56-7-3102
; and
(6)
"Prescription drug" means a drug that under federal or state law is required to be dispensed only pursuant to a prescription order or is restricted to use by individuals authorized by law to prescribe drugs.
Amended by 2021 Tenn. Acts, ch. 405, s 1, eff. 7/1/2021.
Acts 2009 , ch. 355, § 1.
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 32 - PHARMACY BENEFITS (§§ 56-7-3201 — 56-7-3210) › Section 56-7-3202 - Calculation of out-of-pocket costs for prescription drugs and covered services

(a)
When a patient's out-of-pocket cost for a prescription or covered service is percentage-based, the covered entity or pharmacy benefits manager shall calculate the out-of-pocket cost such that when the out-of-pocket cost is added to the amount that the covered entity or pharmacy benefits manager will directly pay to the pharmacy or other dispenser the sum will equal the actual reimbursement.
(b)
The requirements of subsection (a) shall not apply when patient out-of-pocket cost for a prescription or covered service is percentage-based for only a specified portion or predefined subset of drug tiers or specialty drug categories and the remainder of the covered drug prescriptions or services available to the patient are associated with predefined and specific out-of-pocket costs.
Acts 2009 , ch. 355, § 1.
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 32 - PHARMACY BENEFITS (§§ 56-7-3201 — 56-7-3210) › Section 56-7-3203 - Disclosure of the actual reimbursement for a particular prescription or covered service

A covered entity or pharmacy benefits manager shall not in any way restrict, by contract or otherwise, any pharmacy or other dispenser from disclosing to the patient or authorized representative of the patient the actual reimbursement for a particular prescription or covered service. A pharmacy or other dispenser may disclose the actual reimbursement either orally or in writing on any document, including, but not limited to, a receipt, patient profile and summary of the patient's expenditures for prescriptions or covered services.
Acts 2009, ch. 355, § 1.
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 32 - PHARMACY BENEFITS (§§ 56-7-3201 — 56-7-3210) › Section 56-7-3204 - Construction of part

The requirements of this part shall only be construed to apply to policies, contracts and certificates executed, delivered, issued for delivery or renewed in this state on or after January 1, 2010.
Acts 2009, ch. 355, § 1.
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 32 - PHARMACY BENEFITS (§§ 56-7-3201 — 56-7-3210) › Section 56-7-3205 - Calculation of enrollee's contribution to applicable cost sharing requirement

(a)
When calculating an enrollee's contribution to an applicable cost sharing requirement, an insurer shall include cost sharing amounts paid by the enrollee or on behalf of the enrollee by another person.
(b)
Subsection (a) does not apply to a prescription drug for which there is a generic alternative, unless the enrollee has obtained access to the brand name prescription drug through prior authorization, a step therapy protocol, the insurer's exceptions and appeals process, or as specified in §
53-10-204(a)
.
Added by 2021 Tenn. Acts, ch. 405, s 2, eff. 7/1/2021.
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 32 - PHARMACY BENEFITS (§§ 56-7-3201 — 56-7-3210) › Section 56-7-3207 - Report of benefit percentage

A pharmacy benefits manager has a responsibility to report to the plan and the patient any benefit percentage that either are entitled to as a benefit as a covered person.
Added by 2021 Tenn. Acts, ch. 569,s 4, eff. 7/1/2021.
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 32 - PHARMACY BENEFITS (§§ 56-7-3201 — 56-7-3210) › Section 56-7-3209 - Applicability of part

Notwithstanding another law, this part applies to plans governed by the Employee Retirement Income Security Act of 1974 (ERISA) (
29 U.S.C. § 1001
et seq.).
Acts 2022, ch. 1070, § 8.
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 32 - PHARMACY BENEFITS (§§ 56-7-3201 — 56-7-3210) › Section 56-7-3210 - Sanctions

A violation of this part may subject the pharmacy benefits manager or covered entity to the sanctions described in §
56-2-305
.
Added by 2022 Tenn. Acts, ch. 1070, s 10, eff. 1/1/2023.
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 33 - CONTRACTS WITH HEALTH CARE PROVIDERS (§§ 56-7-3301 — 56-7-3304) › Section 56-7-3301 - Part definitions

As used in this part, unless the context otherwise requires:
(1)
"Health care provider" or "provider" means any person or entity performing services regulated pursuant to title 63 or title 68, chapter 11, with whom the health insurance entity has an express and valid network provider agreement or contract;
(2)
"Health insurance entity" has the same meaning as in §
56-7-109
; and
(3)
"Reasonably accurate" means information determined through application by the health insurance entity of contract rates, fee schedules and reimbursement rules and policies in effect as of the date inquiry is made by the provider.
Acts 2009, ch. 334, § 2.
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 33 - CONTRACTS WITH HEALTH CARE PROVIDERS (§§ 56-7-3301 — 56-7-3304) › Section 56-7-3302 - Clear identification of material changes to provider manual

(a)
(1)
A health insurance entity shall provide notice to a healthcare provider of any material change made in the sole discretion of the insurance entity to the entity's previously released provider manual or a reimbursement rule and policy at least sixty (60) days prior to the effective date of the change, and the health insurance entity shall ensure that any such material change is clearly identified in the following manner:
(A)
Disclosing or identifying the change in the provider manual through the use of bold print or a font, or both, with the bold print or font being the same or larger size as the font generally used throughout the policy or manual; and
(B)
Disclosing or identifying the change in the reimbursement rules and policies and the effective date of the change through the use of a separately categorized communication to the provider.
(2)
Any disclosures required under this subsection (a) may be distributed by either:
(A)
An internet web-accessible section associated with a web-accessible current version of the provider manual or reimbursement rules and policies; or
(B)
Written communication sent to a dedicated email address or as stipulated in the contract between the provider and the health insurance entity. The provider shall submit to the health insurance entity a dedicated email address to receive the disclosures required by this subsection (a).
(b)
Notwithstanding any law to the contrary, nothing in this part shall apply to 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; or a contract between a healthcare provider and the state or federal government or their agencies for health services provided through Medicare.
Amended by 2017 Tenn. Acts, ch. 88,s 1, eff. 1/1/2019.
Acts 2009, ch. 334, § 3.
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 33 - CONTRACTS WITH HEALTH CARE PROVIDERS (§§ 56-7-3301 — 56-7-3304) › Section 56-7-3303 - Establishment and maintenance of Internet web site - Web-based preadjudication tool

(a)
By July 1, 2010, a health insurance entity shall establish and maintain an Internet web site, which shall be accessible to health care providers with whom the health insurance entity has an express and a valid network provider agreement or contract.
(b)
(1)
Excluding inpatient claims, every health insurance entity shall make available on the Internet web site established pursuant to subsection (a) a web-based preadjudication tool to be used by a health care provider prior to the provider's submitting either a clean claim as defined in §
56-7-109
or a claim combination to the claims adjudication system utilized by the health insurance entity. The preadjudication tool shall be designed in such a manner as to be capable of:
(A)
Providing reasonably accurate information to a health care provider regarding the manner in which the health insurance entity's claim system will adjudicate claims for specific billing codes or combinations of codes; and
(B)
Providing reasonably accurate information to a health care provider regarding the allowed amount for those claims submitted pursuant to this subdivision (b)(1) based on the health care provider's fee schedule and contract with the health insurance entity for which the claim will be submitted if the claim is determined to be a clean claim.
(2)
Nothing in this subsection (b) shall be construed as requiring the preadjudication tool to reflect the effects of coverage terms and conditions unrelated to application of contract rates, fee schedules and reimbursement rules and policies, including, without limitation, eligibility for coverage, deductibles and copayments, coordination of benefits and coverage limitations and exclusions; and nothing in this subsection (b) shall be construed as requiring the preadjudication tool to respond to a provider when the data submitted by the provider is insufficient to provide the information required by subdivisions (b)(1)(A) and (B).
(c)
Health insurance entity policies affecting the information available to a provider pursuant to subsection (b) shall be easily accessible by a health care provider on the web site established by the health insurance entity pursuant to subsection (a).
Acts 2009 , ch. 334, § 4.
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 33 - CONTRACTS WITH HEALTH CARE PROVIDERS (§§ 56-7-3301 — 56-7-3304) › Section 56-7-3304 - Applicability of part

This part shall not apply to a contract between a health care provider and the state or federal government or their agencies for health care services provided through a program for medicare; the state group insurance program; TennCare or any successor program provided for in title 71, chapter 5; the CoverKids Act of 2006 provided for in title 71, chapter 3, part 11; the Cover Tennessee Act of 2006 provided for in chapter 7, part 30 of this title [repealed]; or the Access Tennessee Act of 2006 provided for in chapter 7, part 29 of this title.
Acts 2009, ch. 334, § 5.
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 34 - UNCLAIMED LIFE INSURANCE BENEFITS ACT (§§ 56-7-3401 — 56-7-3406) › Section 56-7-3401 - Short title

This part shall be known as the "Unclaimed Life Insurance Benefits Act".
Added by 2014 Tenn. Acts, ch. 974,s 1, eff. 7/1/2015.
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 34 - UNCLAIMED LIFE INSURANCE BENEFITS ACT (§§ 56-7-3401 — 56-7-3406) › Section 56-7-3402 - Construction with Uniform Unclaimed Property Act

Nothing in this part shall supersede the Uniform Unclaimed Property Act, compiled in title 66, chapter 29, part 1.
Added by 2014 Tenn. Acts, ch. 974,s 1, eff. 7/1/2015.
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 34 - UNCLAIMED LIFE INSURANCE BENEFITS ACT (§§ 56-7-3401 — 56-7-3406) › Section 56-7-3405 - Failure to comply with part may constitute unfair claims settlement practice - No private cause of action created

A pattern of failures to meet the requirements of this part may constitute an unfair claims settlement practice under the Tennessee Unfair Trade Practices and Unfair Claims Settlement Act of 2009, compiled in chapter 8 of this title. Nothing in this part shall be construed to create or imply a private cause of action for a violation of this part.
Added by 2014 Tenn. Acts, ch. 974,s 1, eff. 7/1/2015.
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 34 - UNCLAIMED LIFE INSURANCE BENEFITS ACT (§§ 56-7-3401 — 56-7-3406) › Section 56-7-3406 - Remittance of proceeds of unclaimed policy, annuity or retained asset account to state

(a)
An insurer is authorized in its discretion, but is not required, to report and remit the proceeds of an unclaimed policy, annuity, or retained asset account to the appropriate state when the insurer, through good faith efforts as evidenced by appropriate documentation, has:
(1)
Identified a person as deceased through a DMF match through a search described in §
56-7-3404
, or other information source;
(2)
Validated such information through a secondary information source;
(3)
Conducted reasonable search efforts for the beneficiary within ninety (90) days after the insurer's validation of the DMF match; and
(4)
Determined that no beneficiary can be located within one (1) year of the conclusion of search efforts described in subdivision (a)(3).
(b)
By remitting the proceeds of an unclaimed policy, annuity or retained asset account to the state pursuant to this section or pursuant to title 66, chapter 29, part 1, an insurer shall be relieved from all liability to any person relating to such proceeds. This relief from liability shall be in addition to any other protections provided by law.
(c)
An insurer shall pay unclaimed proceeds of a policy, annuity, or retained asset account not later than the last day of the period prescribed for such payment under title 66, chapter 29, part 1; provided, that an insurer may pay the unclaimed proceeds of a policy, annuity, or retained asset account prior to the end of such period.
Amended by 2017 Tenn. Acts, ch. 457,s 4, eff. 7/1/2017.
Added by 2014 Tenn. Acts, ch. 974,s 1, eff. 7/1/2015.
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 35 - STEP THERAPY EXCEPTIONS (§§ 56-7-3501 — 56-7-3504) › Section 56-7-3501 - Part definitions

As used in this part:
(1)
"Health benefit plan" has the same meaning as defined in §
56-61-102
;
(2)
"Health carrier" has the same meaning as defined in §
56-61-102
;
(3)
"Healthcare provider" has the same meaning as defined in §
56-61-102
;
(4)
"Interchangeable biological product" means a biological product licensed by the federal food and drug administration and determined to meet the safety standards for determining interchangeability pursuant to
42 U.S.C. § 262(k)(4)
;
(5)
"Pharmaceutical sample" means a unit of a prescription drug that is not intended to be sold;
(6)
"Prescription drug" means a drug that under federal or state law is required to be dispensed only pursuant to a prescription order or is restricted to use by individuals authorized by law to prescribe drugs;
(7)
"Required prescription drug" means a medication that is required as part of a step therapy protocol;
(8)
"Step therapy exception" occurs when a step therapy protocol is overridden in favor of immediate coverage of the healthcare provider's selected prescription drug;
(9)
"Step therapy protocol" means a protocol, policy, or program that establishes a specific sequence in which prescription drugs for a specified medical condition, and medically appropriate for a particular patient, are covered by a health carrier or health benefit plan; and
(10)
"Utilization review organization" means an entity that conducts utilization review, as defined in §
56-6-703
, other than a health carrier or health benefit plan performing utilization review for its own health plans.
Added by 2022 Tenn. Acts, ch. 1020, s 1, eff. 1/1/2023.
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 35 - STEP THERAPY EXCEPTIONS (§§ 56-7-3501 — 56-7-3504) › Section 56-7-3503 - Rulemaking

The commissioner of commerce and insurance shall promulgate rules to effectuate this part. The rules must be promulgated in accordance with the Uniform Administrative Procedures Act, compiled in title 4, chapter 5.
Added by 2022 Tenn. Acts, ch. 1020, s 1, eff. 1/1/2023.
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 35 - STEP THERAPY EXCEPTIONS (§§ 56-7-3501 — 56-7-3504) › Section 56-7-3504 - Applicability

(a)
This part applies to a group health benefit plan or health insurance coverage offered in connection with a group health benefit plan that provides coverage for a prescription drug pursuant to a policy that meets the definition of a step therapy protocol, regardless of whether the policy is described as a step therapy protocol, and includes a state or local insurance program, under title 8, chapter 27.
(b)
This part does not apply to:
(1)
The TennCare program provided for in title 71, chapter 5, or a successor program;
(2)
The CoverKids Act of 2006, compiled in title 71, chapter 3, part 11; or
(3)
The Access Tennessee Act of 2006, compiled in chapter 7, part 29 of this title.
Added by 2022 Tenn. Acts, ch. 1020, s 1, eff. 1/1/2023.
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 36 - TENNESSEE PAID FAMILY LEAVE INSURANCE ACT (§§ 56-7-3601 — 56-7-3605) › Section 56-7-3601 - Short title

This part is known and may be cited as the "Tennessee Paid Family Leave Insurance Act."
Added by 2023 Tenn. Acts, ch. 91, s 1, eff. 1/1/2024.
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 36 - TENNESSEE PAID FAMILY LEAVE INSURANCE ACT (§§ 56-7-3601 — 56-7-3605) › Section 56-7-3602 - Legislative intent

The purpose of this part is to create a new line of insurance, known as paid family leave insurance, under which an insurer licensed to engage in the business of life insurance or disability income insurance in this state may issue policies covering against risk related to paid family leave.
Added by 2023 Tenn. Acts, ch. 91, s 1, eff. 1/1/2024.
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 36 - TENNESSEE PAID FAMILY LEAVE INSURANCE ACT (§§ 56-7-3601 — 56-7-3605) › Section 56-7-3603 - Part definitions

As used in this part:
(1)
"Child" means a biological, adopted, or foster son or daughter; a stepson or stepdaughter; a legal ward; a son or daughter of a domestic partner; or a son or daughter of a person to whom the employee stands in loco parentis who is either:
(A)
Under eighteen (18) years of age; or
(B)
Eighteen (18) years of age or older and incapable of self-care because of a mental or physical disability;
(2)
"Employee" means an individual for whom an employer must complete a Form I-9 pursuant to federal law and regulations, and does not include an independent contractor;
(3)
"Family leave insurance" means an insurance policy issued to an employer related to a benefit program provided to an employee to pay for a percentage or portion of the employee's income loss due to:
(A)
The birth or adoption of a child by the employee;
(B)
Placement of a child with the employee for foster care;
(C)
Care of a family member of the employee who has a serious health condition; or
(D)
The status of a family member of the employee who is a service member on active duty or who has been notified of an impending call or order to active duty;
(4)
"Family member" means:
(A)
A child, spouse, or parent; or
(B)
Another person defined as a family member in a policy of insurance issued under this part;
(5)
"Serious health condition" means an illness, injury, impairment, or physical or mental condition, including transplantation preparation and recovery from surgery related to organ or tissue donation, that involves inpatient care in a hospital, hospice, or residential healthcare facility, continuing treatment or continuing supervision by a healthcare provider as defined in an insurance policy issued under this part; and
(6)
"Service member" means a member of the United States armed forces in active military service.
Added by 2023 Tenn. Acts, ch. 91, s 1, eff. 1/1/2024.
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 36 - TENNESSEE PAID FAMILY LEAVE INSURANCE ACT (§§ 56-7-3601 — 56-7-3605) › Section 56-7-3604 - Policy requirements—Regulatory authority

(a)
Family leave insurance may be written as:
(1)
An amendment or rider to a group disability income policy or life insurance policy, included in a group disability income policy or life insurance policy; or
(2)
A separate group insurance policy purchased by an employer.
(b)
Notwithstanding this title to the contrary, an insurer licensed in this state to sell life insurance or disability income insurance may issue a policy of family leave insurance in accordance with rules adopted by the commissioner.
(c)
The commissioner may promulgate rules to carry out this part and authorize the sale of family leave insurance in this state. The rules must be adopted in accordance with the Uniform Administrative Procedures Act, compiled in title 4, chapter 5.
Added by 2023 Tenn. Acts, ch. 91, s 1, eff. 1/1/2024.
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 36 - TENNESSEE PAID FAMILY LEAVE INSURANCE ACT (§§ 56-7-3601 — 56-7-3605) › Section 56-7-3605 - Policy details and requirements

A policy of insurance issued under this part must set forth the details and requirements with respect to each reason an employee is entitled to take family leave under the policy.
Added by 2023 Tenn. Acts, ch. 91, s 1, eff. 1/1/2024.
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 37 - PRIOR AUTHORIZATION FAIRNESS ACT (§§ 56-7-3701 — 56-7-3722) › Section 56-7-3701 - [Effective 1/1/2025] Short title

This part is known and may be cited as the "Prior Authorization Fairness Act."
Amended by 2023 Tenn. Acts, ch. 395, s 4, eff. 1/1/2025.
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 37 - PRIOR AUTHORIZATION FAIRNESS ACT (§§ 56-7-3701 — 56-7-3722) › Section 56-7-3703 - [Effective 1/1/2025] Requirements for initial adverse determinations

(a)
If a utilization review organization makes an adverse determination for a prior authorization of a healthcare service, then the carrier or organization shall include the following in the notification to the enrollee and the enrollee's healthcare provider requesting the prior authorization on the enrollee's behalf:
(1)
The reasons for the adverse determination and, if applicable, related evidence-based criteria, including a description of missing or insufficient documentation or lack of coverage of the enrollee for the healthcare service;
(2)
The right to appeal the adverse determination;
(3)
Instructions on how to file the appeal; and
(4)
Additional documentation necessary to support the appeal.
(b)
An adverse determination regarding a request for prior authorization for a healthcare service must be made by a licensed physician or a healthcare professional with the same or a similar specialty as the healthcare professional requesting the prior authorization.
(c)
This section does not apply to an initial adverse determination for prescription drugs that are covered under an enrollee's benefit plan.
Amended by 2023 Tenn. Acts, ch. 395, s 4, eff. 1/1/2025.
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 37 - PRIOR AUTHORIZATION FAIRNESS ACT (§§ 56-7-3701 — 56-7-3722) › Section 56-7-3704 - [Effective 1/1/2025] Appeals of an electronic and non-electronic initial adverse determination

(a)
(1)
For prior authorization adverse determination appeals submitted electronically, a utilization review organization shall ensure that such appeals are reviewed or made by a licensed physician or healthcare professional with the same or a similar specialty as the healthcare professional who requested the initial prior authorization. The reviewing healthcare professional shall:
(A)
Possess a current and valid non-restricted license to practice in this state or another state or territory of the United States;
(B)
Be knowledgeable of, and have experience providing, the healthcare services under appeal;
(C)
Not have been directly involved in making the adverse determination; and
(D)
Consider all known clinical aspects of the healthcare service under review, including, but not limited to, a review of all pertinent medical records provided by the enrollee's healthcare provider, and any medical literature provided.
(2)
Utilization review organizations shall perform:
(A)
A non-urgent prior authorization review within seven (7) calendar days; and
(B)
An urgent care prior authorization review within seventy-two (72) hours, plus, if applicable, one (1) additional business day.
(3)
A health carrier or utilization review organization, or a healthcare professional on its behalf, shall not receive compensation as an incentive for issuing an adverse decision.
(b)
(1)
Utilization review organizations shall review all prior authorization adverse determination appeals that are not submitted electronically in accordance with standards set by the National Committee on Quality Assurance.
(2)
For purposes of this part, prior authorization appeals submitted via facsimile are not submitted electronically.
Amended by 2023 Tenn. Acts, ch. 395, s 4, eff. 1/1/2025.
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 37 - PRIOR AUTHORIZATION FAIRNESS ACT (§§ 56-7-3701 — 56-7-3722) › Section 56-7-3706 - [Effective 1/1/2025] Chronic conditions

(a)
If a prior authorization is required for a healthcare service for the treatment of a chronic condition of an enrollee, then the prior authorization remains valid for at least six (6) months, from the date the healthcare professional or provider receives the prior authorization approval, unless the clinical criteria as specified in §
56-7-3707
state otherwise.
(b)
If prior authorization is required for a prescription drug for the treatment of a chronic condition of an enrollee, then the prior authorization remains valid for at least six (6) months from the date the healthcare professional or provider receives the prior authorization approval, unless the clinical criteria as specified in §
56-7-3707
state otherwise.
(c)
This section does not apply to the requirements of a prior authorization for the prescription of a schedule II, III, IV, or V drug. However, notice must be given to the healthcare provider pursuant to this section if prior authorization is or may be required for a schedule II, III, IV or V drug.
(d)
This section does not require a policy of health insurance coverage to cover care, treatment, or services for a health condition that the terms of coverage otherwise completely exclude from the policy's covered benefits without regard for whether the care, treatment, or services are medically necessary.
(e)
This section does not apply to inpatient services.
Amended by 2023 Tenn. Acts, ch. 395, s 4, eff. 1/1/2025.
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 37 - PRIOR AUTHORIZATION FAIRNESS ACT (§§ 56-7-3701 — 56-7-3722) › Section 56-7-3707 - [Effective 1/1/2025] Clinical criteria

(a)
A health carrier shall maintain a complete list of healthcare services for which a prior authorization is required.
(b)
The clinical review criteria for healthcare services or prescription drugs requiring prior authorization must:
(1)
Be based on nationally recognized, generally accepted standards for national, clinical criteria, except where state law provides its own standard;
(2)
Not be arbitrary and must be cited by the utilization review organization;
(3)
Be developed in accordance with the current standards of a national medical accreditation entity;
(4)
Ensure quality of care and access to needed healthcare services;
(5)
Be evidence-based;
(6)
Be sufficiently flexible to allow deviations from norms when justified on a case-by-case basis; and
(7)
Be evaluated and updated in accordance with §
56-7-3718
.
(c)
A claim for failure to obtain prior authorization must not be denied if the prior authorization requirement was not in effect on the date of service on the claim.
Amended by 2023 Tenn. Acts, ch. 395, s 4, eff. 1/1/2025.
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 37 - PRIOR AUTHORIZATION FAIRNESS ACT (§§ 56-7-3701 — 56-7-3722) › Section 56-7-3708 - [Effective 1/1/2025] Electronic prior authorization

(a)
A health carrier or utilization review organization shall accept and respond electronically to prior authorization requests from a healthcare provider submitted through a secure electronic transmission as determined by the carrier or organization.
(b)
If a prior authorization for a prescription drug is submitted electronically using the National Council for Prescription Drug Programs (NCPDP) SCRIPT Standard for electronic prior authorization (ePA) transactions, then the health carrier or utilization review organization must accept and respond to the prior authorization request using the NCPDP SCRIPT Standard for ePA transactions.
(c)
This section does not require a healthcare professional to submit prior authorization requests electronically.
Amended by 2023 Tenn. Acts, ch. 395, s 4, eff. 1/1/2025.
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 37 - PRIOR AUTHORIZATION FAIRNESS ACT (§§ 56-7-3701 — 56-7-3722) › Section 56-7-3709 - [Effective 1/1/2025] Expiration date for a prior authorization

Except as provided in §
56-7-3706
, a prior authorization for an enrollee for a healthcare service is valid for at least six (6) months from the date the prior authorization is approved.
Amended by 2023 Tenn. Acts, ch. 395, s 4, eff. 1/1/2025.
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 37 - PRIOR AUTHORIZATION FAIRNESS ACT (§§ 56-7-3701 — 56-7-3722) › Section 56-7-3710 - [Effective 1/1/2025] Prior authorization and opioid use disorder

(a)
A utilization review organization and health carrier shall not require prior authorization for prescription drugs labeled by the United States food and drug administration for the treatment of opioid use disorder.
(b)
This section does not require a policy to cover any care, treatment, or services for a health condition that the terms of coverage otherwise completely exclude from the policy's covered benefits without regard for whether the care, treatment, or services are medically necessary unless otherwise required by law.
(c)
This section does not apply to behavioral health inpatient services.
Amended by 2023 Tenn. Acts, ch. 395, s 4, eff. 1/1/2025.
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 37 - PRIOR AUTHORIZATION FAIRNESS ACT (§§ 56-7-3701 — 56-7-3722) › Section 56-7-3711 - [Effective 1/1/2025] Medical necessity

The medical necessity or appropriateness of emergency healthcare services must comply with the Consolidated Appropriations Act of 2021 (Pub. L. 116-260). Restrictions on coverage of emergency healthcare services provided by nonparticipating providers must not be greater than restrictions that apply when participating providers provide those services.
Amended by 2023 Tenn. Acts, ch. 395, s 4, eff. 1/1/2025.
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 37 - PRIOR AUTHORIZATION FAIRNESS ACT (§§ 56-7-3701 — 56-7-3722) › Section 56-7-3712 - [Effective 1/1/2025] Changing prior authorization requirements

(a)
A utilization review organization shall provide notice to healthcare providers in its network of each new prior authorization requirement, or restriction or amendment to an existing prior authorization requirement, at least sixty (60) days prior to the effective date of the change.
(b)
A utilization review organization shall provide notice to healthcare providers in its network of each new prior authorization requirement, or restriction or amendment to an existing prior authorization requirement, for a prescription drug at least forty-five (45) days prior to the effective date of the change unless any of the following apply:
(1)
The United States food and drug administration has:
(A)
Issued a statement that calls into question the clinical safety of the drug;
(B)
Required the manufacturers to conduct post-market safety studies and clinical trials after the approval of the drug;
(C)
Issued any drug safety-related labeling changes; or
(D)
Required the manufacturers to implement special risk management programs;
(2)
The drug receives a new approval from the United States food and drug administration and has become available; or
(3)
The United States food and drug administration has approved expanded use of the drug.
(c)
Notice required by this section must be distributed through:
(1)
The utilization review organization's website or the healthcare provider's portal; and
(2)
Written communication sent to a dedicated email address and regular mailing address for the healthcare provider or as stipulated in the contract between the healthcare provider and the utilization review organization. The healthcare provider may be required to submit a dedicated email address and regular mailing address to receive the notices required by this subsection (c).
Amended by 2023 Tenn. Acts, ch. 395, s 4, eff. 1/1/2025.