(a) As used in this section, unless the context otherwise requires:

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Terms Used In Tennessee Code 56-7-2355

  • Contract: A legal written agreement that becomes binding when signed.
  • Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
  • Fraud: Intentional deception resulting in injury to another.
  • 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
  • Representative: when applied to those who represent a decedent, includes executors and administrators, unless the context implies heirs and distributees. 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) “Emergency medical condition” means a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, regardless of the final diagnosis of the symptoms, that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to potentially result in:

(A) Placing the person‘s health in serious jeopardy;
(B) Serious impairment to bodily functions; or
(C) Serious dysfunction of a bodily organ or part;
(2) “Emergency services” means health care items and services furnished in a hospital that are required to determine, evaluate and/or treat an emergency medical condition, until the condition is stabilized, as directed or ordered by a physician or directed by physician or hospital protocol;
(3) “Health benefit plan” means any hospital or medical expense policy, health, hospital or medical service corporation contract, a policy or agreement entered into by a health insurer or a health maintenance organization contract offered by an employer, other plans administered by the state government, or any certificate issued under the policies, contracts or plans. “Health benefit plan” does not include policies or certificates covering only accident, credit, dental, disability income, long-term care, hospital indemnity, medicare supplement as defined in § 1882(g)(1) of the Social Security Act (42 U.S.C. § 1395ss(g)(1)), specified disease, vision care, other limited benefit health insurance, coverage issued as a supplement to liability insurance, workers’ compensation insurance, automobile medical payment insurance, or insurance under which benefits are payable with or without regard to fault and that is statutorily required to be contained in any liability insurance policy or equivalent self-insurance;
(4) “Health insurer” means any entity offering a health benefit plan;
(5) “Participating provider” means a provider who, under a contract with the health insurer or with its contractor or subcontractor, has agreed to provide one (1) or more health care services to enrollees of the health insurer’s health benefit plan with an expectation of receiving payment, other than coinsurance, copayments or deductibles, directly or indirectly from the health insurer;
(6) “Physician” means a person licensed or permitted to practice medicine and surgery under title 63, chapter 6 or 9;
(7) “Provider” means a physician, hospital or other person licensed, accredited or certified to perform specified health care services pursuant to title 63, chapter 6 or 9, or title 68; and
(8) “Stabilized” means, with respect to an emergency medical condition, that no material deterioration of the condition is likely, within a reasonable medical probability, to result from or occur during the transfer of the individual from a facility.
(b)

(1) A health benefit plan shall not deny coverage or payment for emergency services if the symptoms presented by an enrollee of a health benefit plan and recorded by the attending provider indicate that an emergency medical condition could exist, regardless of:

(A) The final diagnosis of the symptoms;
(B) Whether prior authorization was obtained to provide those services; and
(C) Whether the provider furnishing the services has a contractual agreement with the health benefit plan for the provision of the services to the enrollee.
(2) If a participating provider or other authorized representative of a health insurer authorizes emergency services, the health insurer shall not subsequently rescind or modify that authorization after the provider renders the authorized care in good faith and pursuant to the authorization except for payments made as a result of misrepresentation, fraud, omission or clerical error.
(3) Once an enrollee is stabilized pursuant to subdivision (a)(8), a health benefit plan may require as a condition of further coverage that a provider promptly contact the health insurer for prior authorization for continuing treatment, specialty consultations, transfer arrangements or other medically necessary and appropriate care for an enrollee.
(4) Coverage of emergency services shall be subject to applicable copayments, coinsurance and deductibles.
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