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 56-7-1012 - Reimbursement for healthcare services provided during telehealth encounter

(a)
Notwithstanding §
56-7-1002(e)
, a health insurance entity shall provide reimbursement for healthcare services provided during a telehealth encounter in a manner that is consistent with what the health insurance policy or contract provides for in-person encounters for the same service, and shall reimburse for healthcare services provided during a telehealth encounter without distinction or consideration of the geographic location, or any federal, state, or local designation or classification of the geographic area where the patient is located.
(b)
Notwithstanding §
56-7-1003(e)
, a health insurance entity shall provide reimbursement for healthcare services provided during a provider-based telemedicine encounter in a manner that is consistent with what the health insurance policy or contract provides for in-person encounters for the same service, and shall reimburse for healthcare services provided during a provider-based telemedicine encounter without distinction or consideration of the geographic location, or any federal, state, or local designation or classification of the geographic area where the patient is located.
(c)
Reimbursement made pursuant to this section is subject to utilization review under the Health Care Service Utilization Review Act, compiled in chapter 6, part 7 of this title.
(d)
(1)
This section does not require a health insurance entity to provide reimbursement for healthcare services that are not medically necessary, unless the terms and conditions of an applicable health insurance policy provide that coverage.
(2)
As used in this subsection (d):
(A)
For a healthcare service for which coverage or reimbursement is provided under the Medical Assistance Act of 1968, compiled in title 71, chapter 5, part 1, or provided under title 71, chapter 3, part 11, "medically necessary" means a healthcare service that is determined by the bureau of TennCare to satisfy the medical necessity standard set forth in §
71-5-144
; and
(B)
For all other healthcare services, "medically necessary" means healthcare services that a healthcare services provider, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing, or treating an illness, injury, or disease or the symptoms of an illness, injury, or disease, and that are:
(i)
In accordance with generally accepted standards of medical practice;
(ii)
Clinically appropriate, in terms of type, frequency, extent, site and duration; and considered effective for the patient's illness, injury or disease; and
(iii)
Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury or disease.
(e)
This section does not require a healthcare services provider to seek reimbursement from a health insurance entity for healthcare services provided by telehealth or provider-based telemedicine.
(f)
For the purposes of this section:
(1)
"Health insurance entity" has the same meaning as defined in §
56-7-109
and includes managed care organizations participating in the medical assistance program under title 71, chapter 5;
(2)
"Healthcare services" has the same meaning as defined in §
56-61-102
;
(3)
"Healthcare services provider" means an individual acting within the scope of a valid license issued pursuant to title 63 or title 68, chapter 24, part 6, or any state-contracted crisis service provider employed by a facility licensed under title 33;
(4)
"Provider-based telemedicine" has the same meaning as defined in §
56-7-1003
; and
(5)
"Telehealth" has the same meaning as defined in §
56-7-1002
.
(g)
[Deleted by 2022 amendment.]
Amended by 2022 Tenn. Acts, ch. 766, s 1, eff. 4/1/2022.
Acts 2020 (2nd Ex. Sess.), ch. 4, § 8.