Tennessee Code 56-7-1004 – Managed health insurer prohibited from contacting patient of physician’s practice to change referral for services to another provider – Exceptions – Civil penalty

(a) A managed health insurance issuer, as defined by § 56-32-128(a), that has contracted with a physician’s practice to be a part of that health insurance plan’s network of providers shall not directly contact or employ an agent to directly contact a patient of the physician’s practice in an effort to change a referral for services to another provider, unless the following occurs:

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Terms Used In Tennessee Code 56-7-1004

Commissioner: means the commissioner of commerce and insurance. See Tennessee Code 56-1-102
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

(1) The ordering physician, the nurse practitioner under the physician’s supervision, the physician assistant under the physician’s supervision, or a representative of one (1) of the providers is given the opportunity to indicate a particular preference as to the provider of a requested service. In the event a managed health insurance issuer or its agent contacts the patient to suggest alternative providers, the patient shall be notified that the ordering provider indicated a particular preference;

(2) The ordering physician, the nurse practitioner under the physician’s supervision, the physician assistant under the physician’s supervision, or a representative of one (1) of the providers is notified if the patient elects a provider other than that requested by the ordering provider if the ordering provider indicated a particular preference; and

(3) The patient is provided orally or electronically with a disclosure that the patient has a right to discuss the change of referral with the patient’s ordering physician, the nurse practitioner under the physician’s supervision, the physician assistant under the physician’s supervision, or a representative of one (1) of the providers, before the appointment is changed.

(b) Nothing in this section is intended to prohibit an insurer or the insurer’s agent from contacting its enrollees in a health plan to inform the patient that a provider is not included in the patient’s network and that there may be out-of-network costs incurred by using that provider.

(c) The commissioner may assess a civil penalty for a violation of this section pursuant to § 56-2-305.

(d) This section shall not apply to:

(1) TennCare or any successor program provided for in title 71, chapter 5;

(2) CoverKids or any successor program provided for in the CoverKids Act of 2006, compiled in title 71, chapter 3, part 11;

(3) Cover Tennessee or any successor program provided for in the Cover Tennessee Act of 2006, compiled in part 30 of this chapter [repealed];

(4) Access Tennessee or any successor program provided for in the Access Tennessee Act of 2006, compiled in part 29 of this chapter; or

(5) A program for home-based and community-based services to eligible individuals served through a health care financing administration (HCFA) approved waiver.

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Tennessee Code 56-7-1004 – Managed health insurer prohibited from contacting patient of physician’s practice to change referral for services to another provider – Exceptions – Civil penalty – Applicability

Terms Used In Tennessee Code 56-7-1004

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