(a) An enrollee may choose to pay for a healthcare service out-of-pocket from an out-of-network provider. If an enrollee negotiates for a lower cost from an out-of-network provider than the average allowed amount paid by the carrier to a network provider for a comparable healthcare service, and the enrollee pays for the healthcare service out-of-pocket, then the enrollee may send documentation, which may be sent electronically, to the carrier, that provides the following:
Terms Used In Tennessee Code 56-7-610
Allowed amount: means the contractually agreed upon payment amount between a carrier and a healthcare entity participating in the carrier's network, excluding any member deductible, co-pay, or other obligation. See Tennessee Code 56-7-602
Healthcare entity: means : (A) Any healthcare facility licensed under title 33 or 68. See Tennessee Code 56-7-602
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) The healthcare service the enrollee or patient received and the healthcare provider’s name and contact information;(2) The order from the healthcare provider given to the enrollee or patient pursuant to § 56-7-605 and the final bill or statement for the healthcare service;(3) The average payments made by the carrier to network entities or providers for comparable healthcare services if this information is made available to the enrollee pursuant to this part;(4) The negotiated cost of the healthcare service that the enrollee received; and(5) A statement that:
(A) The enrollee paid out-of-pocket for the healthcare services received; and(B) The healthcare entity is not making a claim against the carrier for payment for the healthcare service provided to the enrollee or patient.(b) A carrier that receives the documentation described in subsection (a) shall count the full amount that the enrollee paid out-of-pocket toward the enrollee’s deductible, coinsurance, copayment, or other cost-sharing amount:
(1) If the healthcare service is included under the enrollee’s health plan; and(2) The enrollee negotiated for a lower cost for the healthcare service than the average allowed amount paid by the carrier to network providers for that comparable healthcare service.(c) The amount counted toward an enrollee’s out-of-pocket deductible, coinsurance, copayment, or other cost-sharing amount must not exceed the total amount that the covered person is required to pay out-of-pocket during a contractually agreed upon period of time for healthcare services that are included under the covered person’s insurance plan, and does not carry over once a new contract or agreement period for the insurance plan begins.
