(a) Upon assignment of benefits of a health, accident or sickness insurance policy to a hospital, nursing home, home for the aged, residential HIV supportive living facility, assisted-care living facility, alcohol and drug prevention and/or treatment facility, birthing center, prescribed child care center, ambulatory surgical treatment center, community mental health center, home care organization or other such health care agency or to a doctor or dentist for health care services rendered, by the insured under the policy, the health care agency or doctor or dentist shall be paid the benefits due under such policy to the extent of the assignment within thirty (30) days from the time the insurance company has received a final billing statement for such health care services from such health care agency, doctor or dentist; provided, that the insurance company has received information necessary to determine the extent of liability, if any.

Terms Used In Tennessee Code 68-11-219

  • Ambulatory surgical treatment center: means any institution, place, or building devoted primarily to the maintenance and operation of a facility for the performance of surgical procedures or any facility in which a surgical procedure is utilized to terminate a pregnancy. See Tennessee Code 68-11-201
  • Assisted-care living facility: means a facility, building, establishment, complex or distinct part thereof that accepts primarily aged persons for domiciliary care and services as described in this section. See Tennessee Code 68-11-201
  • Birthing center: means any institution, facility, place or building devoted exclusively or primarily to the provision of routine delivery services and postpartum care for mothers and their newborn infants. See Tennessee Code 68-11-201
  • Dentist: means a doctor of dental science who is duly licensed to practice dentistry in this state. See Tennessee Code 68-11-201
  • Executive director: means the executive director of the health facilities commission. See Tennessee Code 68-11-201
  • Facility: means any institution, place or building providing health care services that is required to be licensed under this chapter. See Tennessee Code 68-11-201
  • Home for the aged: means a home represented and held out to the general public as a home which accepts primarily aged persons for relatively permanent, domiciliary care. See Tennessee Code 68-11-201
  • Hospital: means any institution, place, building or agency represented and held out to the general public as ready, willing and able to furnish care, accommodations, facilities and equipment for the use, in connection with the services of a physician or dentist, of one (1) or more nonrelated persons who may be suffering from deformity, injury or disease or from any other condition for which nursing, medical or surgical services would be appropriate for care, diagnosis or treatment. See Tennessee Code 68-11-201
  • Interest rate: The amount paid by a borrower to a lender in exchange for the use of the lender's money for a certain period of time. Interest is paid on loans or on debt instruments, such as notes or bonds, either at regular intervals or as part of a lump sum payment when the issue matures. Source: OCC
  • Month: means a calendar month. See Tennessee Code 1-3-105
  • Nursing home: means any institution, place, building or agency represented and held out to the general public for the express or implied purpose of providing care for one (1) or more nonrelated persons who are not acutely ill, but who do require skilled nursing care and related medical services. See Tennessee Code 68-11-201
  • Prescribed child care center: means a nonresidential child care, health care/child care center providing physician prescribed services and appropriate developmental services for six (6) or more children who are medically or technology dependent and require continuous nursing intervention. See Tennessee Code 68-11-201
  • Year: means a calendar year, unless otherwise expressed. See Tennessee Code 1-3-105
(b) It is the duty of the insurance company to request the information required for payment of such benefits within fifteen (15) days after receiving claim for benefits under such policy.
(c)

(1) If any portion of the claim is under dispute because of the nature, necessity or charges for the services, the insurer shall, within the thirty-day period, pay the amount of the claim that is not in dispute and notify the health care provider in writing of the reason or reasons for the dispute and the amount in dispute.
(2) If the dispute is due to the need for verification of services rendered and cannot otherwise be resolved by the insurer and health care provider, then the insurer shall schedule an audit on the premises of the health care provider within thirty (30) days of the notice and shall pay the amount determined to be due under the audit within thirty (30) days of the date of the audit done on the premises.
(d)

(1) Where a single confinement exceeds thirty (30) days, the provider may submit bills to the insurer on a thirty-day interval.
(2) When the insurer receives a billing statement of this nature, the insurer shall pay the claim for the period covered by the bill in accordance with this section.
(e) If any portion of an assigned claim remains unpaid sixty (60) days after a billing statement from the assignee is received by the insurance company, the assignee of the claim may add an interest charge to the unpaid portion of the claim, with the accrual of such interest charge commencing on the thirty-first day, at an interest rate not to exceed one percent (1%) per month for an annual effective rate of interest of twelve percent (12%) per year; provided, that such interest shall not be allowed for that portion of any claim for which the insurance company has not received any requested information necessary to determine the extent of its liability, if any, or for that portion of any claim to which subsection (c) applies.
(f) If the health care provider offers a prompt payment discount, it shall apply to any portion of the claim paid within the period specified in the prompt payment plan.
(g) Failure of an insurer to comply with this section may be reported to the executive director.
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