Beneficiary: A person who is entitled to receive the benefits or proceeds of a will, trust, insurance policy, retirement plan, annuity, or other contract. Source: OCC
Code: includes the Tennessee Code and all amendments and revisions to the code and all additions and supplements to the code. See Tennessee Code 1-3-105
Contract: A legal written agreement that becomes binding when signed.
Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
Fraud: Intentional deception resulting in injury to another.
person: includes an individual, insurer, company, association, organization, Lloyds, society, reciprocal insurer or interinsurance exchange, partnership, syndicate, business trust, corporation, agent, general agent, broker, solicitor, service representative, adjuster, and every legal entity. See Tennessee Code 56-32-102
Provider: means any physician, hospital or other person that is licensed or otherwise authorized in this state to furnish health care services. See Tennessee Code 56-32-102
(1) If authorization is given and a pharmacy claim is adjudicated by an HMO or its agent to any pharmacy services provider for care to be delivered to a covered beneficiary under any evidence of coverage issued by the HMO, including those organizations participating in the TennCare program, collectively referred to as “organization,” then the organization acting directly or by delegation through an agent acting on behalf of the organization shall not subsequently rescind or modify that authorization or deny the authorized payment to the pharmacy services provider for the authorized service after the provider renders the authorized service in good faith and pursuant to the authorization, except for payments made as a result of the provider’s misrepresentation or fraud.(2) If the bureau of TennCare provides notice to the HMO or its agent that a person is eligible to participate in the TennCare program, and, if based on good faith reliance on the information, the HMO makes a payment to a pharmacy provider for providing pharmacy services to the person enrolled in the TennCare program, and if the bureau of TennCare later rescinds the eligibility for the person, then the bureau of TennCare shall remain liable to the HMO for any amount the HMO paid to the provider for the pharmacy services. The bureau of TennCare shall not be liable when the eligibility is rescinded in the case of fraud or death as defined in the contract. The bureau of TennCare shall not be liable due to an error or delay on the part of the managed care organization or its agents in processing eligibility information received from the bureau of TennCare.(b) Notwithstanding subsection (a), any organization may request the pharmacy to adjust or correct an adjudicated claim to correct incorrect data elements, including incorrect billing units, incorrect national drug code (NDC) numbers and incorrect prescriber identification numbers submitted in error and in good faith by the pharmacy. An organization shall provide the pharmacy an opportunity to correct claims submitted by the pharmacy in good faith. If the pharmacy does not correct the adjudicated claim requested within thirty (30) days of receipt of the request, then the organization may rescind, modify or recoup the funds paid on the requested claim and shall not be in violation of this section.
