(a) As used in this section only, the following terms have the meaning as indicated:
Terms Used In Tennessee Code 56-7-132 v2
Covered person: means a person on whose behalf a health insurance entity offering health insurance coverage is obligated to pay benefits or provide services. See Tennessee Code 56-7-110
Health care provider: means any person or entity performing services regulated pursuant to title 63 or title 68, chapter 11. See Tennessee Code 56-7-110
Obligation: An order placed, contract awarded, service received, or similar transaction during a given period that will require payments during the same or a future period.
Person: means any association, aggregate of individuals, business, company, corporation, individual, joint-stock company, Lloyds-type organization, organization, partnership, receiver, reciprocal or interinsurance exchange, trustee or society. See Tennessee Code 56-16-102
(1) “Original health insurer” means a health insurance entity as defined in § 56-7-109 that has verified eligibility for the date of service, or has communicated to a health care provider prior authorization or precertification for a service to be provided, to a person believed by the original health insurer to be covered under the group health care policy as of the date that eligibility was verified or prior authorization or precertification is issued, but that no longer covers the insured individual at the time the service is performed;(2) “Successor coverage health claim” means a claim for benefits or reimbursement under a group health care policy when the health care services performed were based upon verification of eligibility or were authorized by an original health insurer, but the original health insurer coverage has been replaced by a successor health insurer on or before the date that the services are provided to the covered person; and(3) “Successor health insurer” means a health insurance entity as defined by § 56-7-109 that provided group health coverage for the person at the time the original health insurer verified eligibility or approved prior authorization or precertification for the person or at the time the service was actually performed.(b) In the case of a successor coverage health claim, and notwithstanding the provisions of a successor health insurer group health care policy, a successor health insurer shall not:
(1) Deny a claim because of failure to submit the claim timely; provided, that the claim was submitted within one hundred eighty (180) days of the date the claim was denied by the original health insurer; or(2) Deny the claim because of the covered person’s failure to obtain prior authorization or precertification, if the successor insurer would have granted prior authorization or precertification for the service had it been asked to do so prior to the health care service being rendered to the covered person.(c) Except as may result from the application of subsection (b), nothing in this section shall require a successor health insurer to pay any claim or make reimbursement for any services not covered under the terms of its group health care policy.(d) This section shall not apply to TennCare or any successor program provided for in title 71, chapter 5, or CoverKids or any successor program provided for in title 71, chapter 3, part 11.(e) Nothing in this section shall create any obligation by an original health insurer to a successor health insurer to provide proof of eligibility inquiry by a health care provider.(f) Original health insurers and successor health insurers shall comply with the Prior Authorization Fairness Act, compiled in part 37 of this chapter.
