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.
Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
Fraud: Intentional deception resulting in injury to another.
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) If authorization is given and a pharmacy claim is adjudicated by a health insurer or its agent to any pharmacy services provider for care to be delivered to a covered beneficiary under any individual, franchise, blanket or group health insurance policy, medical service plan corporationcontract, hospital service corporation contract, hospital and medical service corporation contract or fraternal benefit society, the health insurer acting directly or by delegation through an agent acting on behalf of the health insurer 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 health insurer 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 health insurer 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 health insurer for any amount the health insurer 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 The bureau of TennCare shall not be liable when the eligibility is rescinded in the case of fraud or death as defined in the contract.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.
