Tennessee Code Annotated

Title 56: Insurance

Chapter 7: Policies and Policyholders

Part 10: Health and Accident Insurance

TCA 56-7-1001: Credentialing and contracting of health care providers by health insurance entities.

(a) (1) A health insurance entity, as defined in SC 56-7-109, regardless of status as a participating organization of the Council on Affordable Quality Healthcare (CAQH) or its successor, shall notify the health care provider of the results of the provider's clean CAQH credentialing application and shall notify the health care provider as to whether or not the health insurance entity is willing to contract with that provider within ninety (90) calendar days after receipt of the completed application.

(2) A clean CAQH application means an application that has no defect, misstatement of facts, improprieties, including a lack of any required substantiating documentation, or particular circumstance requiring special treatment that impedes prompt credentialing.

(b) Unless otherwise required by a national accrediting body, a health insurance entity shall accept and begin processing a completed credentialing application, whether a CAQH or the health insurance entity's application, as early as ninety (90) calendar days before the anticipated employment start date of the health care provider.

(c) Unless otherwise required by a national health insurance entity accrediting body, a health insurance entity shall not mandate, in order to process a credentialing application, whether a CAQH or the health insurance entity's application, that a health care provider have an active health care liability insurance policy and bear the unnecessary costs of the premiums before the provider's employment start date.

(d) No health insurance entity shall reflect, in either written material sent to its members or on a web site available to its members, that a health care provider is an in-network provider or that the provider's credentialing application is pending approval until such time as a contract is signed by both the provider and the health insurance entity and the provider is eligible to be reimbursed as an in-network provider.

(e) (1) Nothing in this section requires a health insurance entity to contract with a provider if the health insurance entity and the provider do not agree on the terms and conditions of the provider contract.

(2) Nothing in this section creates a private cause of action against a health insurance entity.

History: cts 2007, ch. 365, SC 1; 2012, ch. 798, SC 21.