68-11-219 - Payment to health care agency of assigned insurance benefits Insurer's duty to request information. - Tennessee Statutes

68-11-219. Payment to health care agency of assigned insurance benefits Insurer's duty to request information.

(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.

(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 the provisions of 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 the provisions of subsection (c) apply.

(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 the provisions of this section may be reported to the commissioner.

[Acts 1978, ch. 881, § 1; 1980, ch. 686, § 1; 1982, ch. 690, § 1; T.C.A., § 53-1331; Acts 1988, ch. 821, § 1; 1989, ch. 205, § 1; 1990, ch. 758, § 1; 1991, ch. 423, §§ 1, 2; 1993, ch. 234, § 19; 1994, ch. 747, § 5; 1996, ch. 674, § 10; 1996, ch. 818, § 3; 1998, ch. 1021, § 4; 2000, ch. 981, § 93.]