Part Definitions — Correction of Payment Errors — Retroactive Denial of Reimbursements
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As used in this part:
“Covered person” means a person on whose behalf a health insurance entity offering health insurance coverage is obligated to pay benefits or provide services;
“Health care provider” means any person or entity performing services regulated pursuant to title 63 or title 68, chapter 11;
“Health insurance coverage” has the same meaning as in § 56-7-109;
“Health insurance entity” has the same meaning as in § 56-7-109; and
“Recoupment” means the action by a health insurance entity to recover amounts previously paid to a health care provider by withholding or setting off the amounts against current payments to the health care provider.
A health insurance entity shall not be required to correct a payment error to a health care provider if the provider's request for a payment correction is filed more than eighteen (18) months after the date that the health care provider received payment for the claim from the health insurance entity.
Except in cases of fraud committed by the health care provider, a health insurance entity may only recoup reimbursements to the provider during the eighteen-month period after the date that the health insurance entity paid the claim submitted by the health care provider.
A health insurance entity that recoups reimbursement to a health care provider under this section shall give the health care provider a written or electronic statement specifying the basis for the recoupment and the statement shall contain, at a minimum, the information required by subsection (g).
If a health insurance entity determines that payment was made for services not covered under the covered person's health insurance coverage, the health insurance entity shall give written notice to the health care provider of its intent to recoup a previously paid claim and may:
Request a refund from the health care provider; or
Make a recoupment of the payment from the health care provider in accordance with subsection (g).
The notice required by subdivision (e)(1) may be included in the results of an audit submitted to the health care provider.
Notwithstanding subsection (c), if a health insurance entity or an agent contracted to provide eligibility verification, verifies that an individual is a covered person and if the health care provider provides services to the individual in reliance on the verification, the health insurance entity may not thereafter recoup a claim on the basis that the individual is not a covered person unless the recoupment occurs within six (6) months of the date that the health insurance entity paid the claim; otherwise, the health insurance entity is barred from making the recoupment unless there was fraud by the health care provider.
If a health insurance entity chooses to recoup from a health care provider amounts previously paid pursuant to subsection (c) or (e), the health insurance entity shall provide the health care provider written documentation that specifies:
The amount of the recoupment;
The covered person's name to whom the recoupment applies;
The patient identification number;
The date or dates of service;
The service or services on which the recoupment is based; and
The pending claims being recouped or that future claims will be recouped.
If the commissioner finds a health insurance entity has failed to comply with this section, the commissioner may impose a penalty of two (2) times the amount of the claim or seven hundred fifty dollars ($750), whichever amount is less.
In the alternative, the health care provider may seek injunctive or other appropriate relief in the chancery or circuit court in the county where the provider resides or practices.
The commissioner shall adopt rules and regulations to ensure compliance with this section. The rules shall be adopted in accordance with the Uniform Administrative Procedures Act, compiled in title 4, chapter 5, and may be promulgated by emergency rulemaking.
This section shall not be waived, voided or nullified by contract; provided, however, that the health insurance entity and the health care provider are permitted to toll the time periods contained in subsections (c) and (f) through mutually negotiated and separate tolling agreements if both parties agree to toll or extend the time periods established by subsections (c) and (f).
This section shall not interfere or otherwise repeal the following:
The prompt payment appeals process described in § 56-32-126;
The authority of a receiver appointed by the commissioner pursuant to chapter 9 of this title to audit or collect overpayment made to providers more than eighteen (18) months from the date that the managed care organization (MCO) paid the claim;
The authority of the TennCare bureau to collect overpayments made to providers more than eighteen (18) months from the date that the MCO paid the claim if discovered and verified by the bureau pursuant to an audit of an MCO; or
The subrogation rights or authority of the TennCare bureau.
Health insurance entities that contract directly with the TennCare bureau in the provision of services for TennCare recipients are specifically excluded from this section only for the products and services made by the health insurance entities on behalf of the TennCare bureau.
In order to ensure that the original intent of this section is followed and to prevent any entity from circumventing the time frames established by this section, only a health insurance entity, or the health insurance entity's agent, that contracts with health care providers or is responsible for paying contracted or noncontracted health care providers may seek to recover any payments made to those health care providers. No other entity may pursue recoupments governed by this section.