(a) A health carrier or utilization review organization shall pay a healthcare provider at the contracted payment rate for a healthcare service provided by the healthcare provider per an approved prior authorization unless: (1) The healthcare provider knowingly and materially misrepresented the healthcare service in the prior authorization request with the specific intent to deceive and obtain an unlawful payment from the health carrier;(2) The healthcare provider was no longer contracted with the patient's health benefit plan on the date the healthcare service was provided;(3) The healthcare provider failed to meet the timely filing requirements of the health carrier; or(4) The health carrier does not have liability for a claim.(b) A health carrier shall pay a healthcare provider for performing a healthcare service if the prior authorization for the service was obtained by another healthcare provider.(c) The health carrier shall provide reimbursement for healthcare services retroactively deemed medically necessary, regardless of when prior authorization was approved, for a maximum period of eighteen (18) months.(d) Payment must be guaranteed when a prior authorization submitted ively deemed medically necessary, regardless of when prior authorization was approved, for a maximum period of eighteen (18) months.(d) Payment must be guaranteed when a prior authorization submitted under § 56-7-3705 is approved.(e) This section does not apply to prescription drugs that are covered under an enrollee's benefit plan.Amended by 2023 Tenn. Acts, ch. 395, s 4, eff. 1/1/2025.
Tennessee Legal Code