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.
Public law: A public bill or joint resolution that has passed both chambers and been enacted into law. Public laws have general applicability nationwide.
Record: means information that is inscribed on a tangible medium or that is stored in an electronic or other medium and is retrievable in a perceivable form. See Tennessee Code 1-3-105
State: when applied to the different parts of the United States, includes the District of Columbia and the several territories of the United States. See Tennessee Code 1-3-105
(1) “Health insurance entity” has the same meaning as defined in § 56-7-109 and includes managed care organizations participating in the medical assistance program under title 71, chapter 5;(2) “Healthcare services” has the same meaning as defined in § 56-61-102;(3) “Healthcare services provider” means an individual acting within the scope of a valid license issued pursuant to title 63 or title 68, chapter 24, part 6, or any state-contracted crisis service provider employed by a facility licensed under title 33;(4) “Healthcare system” means two (2) or more healthcare organizations as defined in § 63-1-150, that are affiliated through shared ownership or pursuant to a contractual relationship that controls payment terms and service delivery;(5) “Practice group” means two (2) or more healthcare services providers that share a common employer for the purposes of the healthcare services providers’ clinical practice;(6) “Provider-based telemedicine”:
(A) Means the use of Health Insurance Portability and Accountability Act (HIPAA) (42 U.S.C. § 1320d et seq.) compliant real-time, interactive audio, video telecommunications, or electronic technology, or store-and-forward telemedicine services, used over the course of an interactive visit by a healthcare services provider to deliver healthcare services to a patient within the scope of practice of the healthcare services provider when:
(i) The healthcare services provider is at a qualified site other than the site where the patient is located and has access to the relevant medical record for that patient;(ii) The patient is located at a location the patient deems appropriate to receive the healthcare service that is equipped to engage in the telecommunication described in this section; and(iii)(a) The healthcare services provider makes use of HIPAA compliant real-time, interactive audio, video telecommunications or electronic technology, or store-and-forward telemedicine services to deliver healthcare services to a patient within the scope of practice of the healthcare services provider as long as the healthcare services provider, the healthcare services provider’s practice group, or the healthcare system has established a provider-patient relationship by submitting to a health insurance entity evidence of an in-person encounter between the healthcare service provider, the healthcare services provider’s practice group, or the healthcare system and the patient within sixteen (16) months prior to the interactive visit;(b) The requirement of an in-person encounter between the healthcare services provider, the healthcare services provider’s practice group, or the healthcare system and the patient within sixteen (16) months prior to the interactive visit is tolled for the duration of a state of emergency declared by the governor pursuant to § 58-2-107; provided, that the healthcare services provider or the patient, or both, are located in the geographical area covered by the applicable state of emergency; and(c) The requirement of an in-person encounter between the healthcare services provider, the healthcare services provider’s practice group, or the healthcare system and the patient within sixteen (16) months prior to the interactive visit does not apply to a patient who is receiving an initial behavioral health evaluation or assessment;(B) Does not include:
(i) An audio-only conversation;(ii) An electronic mail message or phone text message;(iii) A facsimile transmission;(iv) Remote patient monitoring; or(v) Healthcare services provided pursuant to a contractual relationship between a health insurance entity and an entity that facilitates the delivery of provider-based telemedicine as the substantial portion of the entity’s business; and(C) Notwithstanding subdivisions (a)(6)(A) and (B), includes Health Insurance Portability and Accountability Act (HIPAA) (42 U.S.C. § 1320d et seq.) compliant audio-only conversation for the provision of:
(i) Behavioral health services when the means described in subdivision (a)(6)(A) are unavailable; and(ii) Healthcare services when the means described in subdivision (a)(6)(A) are unavailable;(7) “Qualified site” means the primary or satellite office of a healthcare services provider, a hospital licensed under title 68, a facility recognized as a rural health clinic under federal medicare regulations, a federally qualified health center, a facility licensed under title 33, or any other location deemed acceptable by the health insurance entity; and(8) “Store-and-forward telemedicine services”:
(A) Means the use of asynchronous computer-based communications between a patient and healthcare services provider at a distant site for the purpose of diagnostic and therapeutic assistance in the care of patients; and(B) Includes the transferring of medical data from one (1) site to another through the use of a camera or similar device that records or stores an image that is sent or forwarded via telecommunication to another site for consultation.(b) Healthcare services provided through a provider-based telemedicine encounter must comply with state licensure requirements promulgated by the appropriate licensure boards. Provider-based telemedicine providers are held to the same standard of care as healthcare services providers providing the same healthcare services through in-person encounters.(c) A provider-based telemedicine provider who seeks to contract with or who has contracted with a health insurance entity to participate in the health insurance entity’s network is subject to the same requirements and contractual terms as any other healthcare services provider in the health insurance entity’s network.(d) A health insurance entity:
(1) Shall provide coverage under a health insurance policy or contract for covered healthcare services delivered through provider-based telemedicine;(2) Shall reimburse a healthcare services provider for a healthcare service covered under an insured patient’s health insurance policy or contract that is provided through provider-based telemedicine without any distinction or consideration of the geographic location or any federal, state, or local designation, or classification of the geographic area where the patient is located;(3) Shall not exclude from coverage a healthcare service solely because it is provided through provider-based telemedicine and is not provided through an in-person encounter between a healthcare services provider and a patient; and(4) Shall reimburse healthcare services providers who are out-of-network for provider-based telemedicine care services under the same reimbursement policies applicable to other out-of-network healthcare services providers.(e) A health insurance entity shall provide coverage for healthcare services provided during a provider-based telemedicine encounter in a manner that is consistent with what the health insurance policy or contract provides for in-person encounters for the same service, and shall reimburse for healthcare services provided during a provider-based telemedicine encounter without distinction or consideration of the geographic location, or any federal, state, or local designation or classification of the geographic area where the patient is located.(f) This section does not require a health insurance entity to pay total reimbursement for a provider-based telemedicine encounter in an amount that exceeds the amount that would be paid for the same service provided by a healthcare services provider for an in-person encounter.(g)(1) This section does not require a health insurance entity to provide coverage for healthcare services that are not medically necessary, unless the terms and conditions of an applicable health insurance policy provide that coverage.(2) As used in subdivision (g)(1):
(A) For a healthcare service for which coverage or reimbursement is provided under the Medical Assistance Act of 1968, compiled in title 71, chapter 5, part 1, or provided under title 71, chapter 3, part 11, “medically necessary” means a healthcare service that is determined by the bureau of TennCare to satisfy the medical necessity standard set forth in 71-5-144; and(B) For all other healthcare services, “medically necessary” means healthcare services that a healthcare services provider, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing, or treating an illness, injury, or disease or the symptoms of an illness, injury, or disease, and that are:
(i) In accordance with generally accepted standards of medical practice;(ii) Clinically appropriate, in terms of type, frequency, extent, site and duration; and considered effective for the patient’s illness, injury or disease; and(iii) Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury, or disease.(3) This section does not require a health insurance entity to provide coverage for healthcare services delivered by means of provider-based telemedicine if the applicable health insurance policy would not provide coverage for the same healthcare services if delivered by in-person means.(4) This section does not require a health insurance entity to reimburse a healthcare services provider for healthcare services delivered by means of provider-based telemedicine if the applicable health insurance policy would not reimburse that healthcare services provider if the same healthcare services had been delivered by in-person means.(h) Any provisions not required by this section are governed by the terms and conditions of the health insurance policy or contract.(i) Provider-based telemedicine is subject to utilization review under the Health Care Service Utilization Review Act, compiled in chapter 6, part 7 of this title.(j)(1) This section does not apply to accident-only, specified disease, hospital indemnity, plans described in § 1251 of the Patient Protection and Affordable Care Act, Public Law 111-148, as amended and § 2301 of the Health Care and Education Reconciliation Act of 2010, Public Law 111-152, as amended (both in 42 U.S.C. § 18011), plans governed by the Employee Retirement Income Security Act of 1974 (ERISA) (29 U.S.C. § 1001 et seq.), medicare supplement, disability income, long-term care, or other limited benefit hospital insurance policies.(2) This section does apply to the basic health plans authorized under title 8, chapter 27, parts 1, 2, 3, and 7.(k) A healthcare provider, office staff, or party acting on behalf of the healthcare provider submitting for reimbursement of an audio-only encounter under subdivision (a)(6)(C)(ii) shall:
(1) Confirm and maintain documentation that the patient:
(A) Does not own the video technology necessary to complete an audio-video provider-based telemedicine encounter;(B) Is at a location where an audio-video encounter cannot take place due to lack of service; or(C) Has a physical disability that inhibits the use of video technology; and(2) Notify the patient that the financial responsibility for the audio-only encounter will be consistent with the financial responsibility for other in-person or video encounters, prior to the audio-only telemedicine encounter.
