(a) As used in this section:

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Terms Used In Tennessee Code 63-1-171

  • 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.
  • Jurisdiction: (1) The legal authority of a court to hear and decide a case. Concurrent jurisdiction exists when two courts have simultaneous responsibility for the same case. (2) The geographic area over which the court has authority to decide cases.
  • Minor: means any person who has not attained eighteen (18) years of age. 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
  • written: includes printing, typewriting, engraving, lithography, and any other mode of representing words and letters. See Tennessee Code 1-3-105
(1) “Communication” means written or electronic correspondence among a healthcare facility, health insurance entity, or provider concerning a prior authorization;
(2) “Health insurance coverage” has the same meaning as defined in § 56-7-109;
(3) “Health insurance entity” means an entity subject to the insurance laws of this state, or subject to the jurisdiction of the commissioner of commerce and insurance, that contracts or offers to contract to provide health insurance coverage, including, but not limited to, an insurance company, a health maintenance organization, and a nonprofit hospital and medical service corporation;
(4) “Healthcare facility”:

(A) Means an institution, place, or building providing healthcare services that is required to be licensed under title 68, chapter 11; and
(B) Excludes emergency room and in-patient services provided at a hospital, as defined in § 68-11-201;
(5) “Healthcare service” means a service for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease;
(6) “Minor” means an individual who has not attained eighteen (18) years of age;
(7) “Policyholder” means an individual who has contracted with a health insurance entity for healthcare services coverage; and
(8) “Provider” means an individual or entity performing services regulated pursuant to this title or title 68, chapter 11, with whom the health insurance entity has an express and valid network provider agreement or contract.
(b) Except as provided in subsection (d), a provider shall notify a patient of communication between the provider and a health insurance entity or healthcare facility concerning additional information needed to process a prior authorization request for the patient within five (5) business days after the communication has occurred. The notification must include a brief summary of the communication or a copy of the communication.
(c) The provider shall notify the patient via electronic means, such as by email or through an online patient portal offered by the provider, unless the patient requests, in writing, an alternative notification method.
(d) If the patient is a minor, then the provider must notify the policyholder whose health insurance coverage covers the minor.
(e) This section does not apply to the TennCare program or a successor to the program provided for in the Medical Assistance Act of 1968, compiled in title 71, chapter 5, or to the CoverKids Act of 2006, compiled in title 71, chapter 3, part 11 or a successor program.
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