(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:

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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
  • carrier: means a health insurance entity as defined in §. See Tennessee Code 56-7-602
  • Comparable healthcare service: includes , but is not limited to:
    (A) Physical and occupational therapy services. See Tennessee Code 56-7-602
  • Contract: A legal written agreement that becomes binding when signed.
  • Health plan: means health insurance coverage as defined in §. 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.
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