(a) A third party, upon receiving a request from a plan, shall provide information identifying persons covered by third parties for medical services. As a condition of doing business in this state or providing coverage to residents of this state, and subject to subsection (c), a third-party for medical services shall, upon request from a plan or an administrator, electronically provide full eligibility files that contain information to determine the period a plan participant may be or may have been covered by the third party. The eligibility files must include the nature of the coverage that is or was provided by the third party; the name, address, date of birth, social security number, group number, and identifying number of the plan under which the plan participant may receive benefits; and the effective and termination dates for the coverage.
Terms Used In Tennessee Code 8-27-905
Administrator: means : (A) An individual, either employed by, or contracted with, the sponsor or the plan to provide administrative services on behalf of the plan. See Tennessee Code 8-27-901
Litigation: A case, controversy, or lawsuit. Participants (plaintiffs and defendants) in lawsuits are called litigants.
Obligation: An order placed, contract awarded, service received, or similar transaction during a given period that will require payments during the same or a future period.
plan: includes those to which the primary insured pays to the plan a nominal fee for the primary insured and any insureds whose relationship to the primary insured allows them to receive benefits under the plan. See Tennessee Code 8-27-901
Service: means service as a general employee, a teacher, a state police officer, a wildlife officer, a firefighter, a police officer, a state judge, a county judge, an attorney general, a commissioner or a county official which is paid for by an employer, and also includes service for which a former member of the general assembly is entitled to under former §. See Tennessee Code 8-34-101
third party: means a person or entity that contracts with either the plan or the third-party administrator to provide payment for claims of healthcare items or services for plan participants. See Tennessee Code 8-27-901
written: includes printing, typewriting, engraving, lithography, and any other mode of representing words and letters. See Tennessee Code 1-3-105
(b) A third party is not liable to a policyholder for proper release to a plan or an administrator of the information contained in the eligibility files provided pursuant to subsection (a).(c) The third party shall provide the eligibility files pursuant to subsection (a) upon receipt of written request from a plan or an administrator with the third party establishing confidentiality requirements for the information. The plan or administrator may serve the request on the third party electronically or by mail.(d) Third parties shall respond to all written inquiries by a plan regarding a claim for payment for any healthcare item or service that are submitted not later than three (3) years after the date of the provision of the healthcare item or service, or within three (3) years of conclusion of litigation. Third parties shall respond to a plan’s or administrator’s request for payment by providing payment on the claim, a written request for additional information with which to process the claim, or a written reason for denial of the claim within ninety (90) days of receipt of written proof of loss or claim for payment for healthcare services provided to, for the benefit of, or on behalf of, a plan participant. Such response from a third-party notice may be sent to the plan electronically if the plan administrator has provided an email address or other electronic means of communication, or by certified mail with either a return signature or electronic receipt. Notwithstanding title 56, a failure to pay or deny a claim within one hundred eighty (180) days after receipt of the claim constitutes a waiver of any objection to the claim and an obligation to pay the claim.
