Tennessee Code Annotated

Title 56: Insurance

Chapter 32: Health Maintenance Organization Act of 1986

TCA 56-32-130: Notice for providers.

(a) A managed health insurance issuer shall not terminate or nonrenew a contract with a health care provider, or take other retaliatory action against a health care provider, because the provider:

(1) Communicated with an enrollee with respect to the enrollee's health status, health care or treatment options, if the health care provider is acting in good faith and within the provider's scope of practice as defined by law;

(2) Disclosed accurate information about whether a health care service or treatment is covered by an enrollee's health coverage plan; or

(3) Expressed personal disagreement with the decision made by the managed health insurance issuer regarding treatment or coverage provided to a patient of the provider, or assisted the enrollee in pursuing the grievance process relative to the decision of the managed health insurance issuer; provided the health care provider makes it clear that the provider is acting in a personal capacity, and not as a representative of, or on behalf of, the managed health insurance issuer.

(b) Nothing in this section shall prohibit:

(1) A managed health insurance issuer from taking action against a provider if the health plan has evidence that the provider's actions are illegal, constitute health care liability or are contrary to accepted medical practices;

(2) A contract provision or directive that requires any contracting party to keep confidential or to not use or disclose specific amounts paid to a provider, provider fee schedules, provider salaries and other proprietary information of a specific contract issued by a managed health insurance issuer; or

(3) A managed health insurance issuer from making a determination not to pay for a particular medical treatment or service or to enforce reasonable peer review or utilization review protocols.

(c) Nothing in this section shall be construed as permitting retaliatory action by a managed health insurance issuer against a provider because the provider disclosed to the patient accurate information regarding the basis of the provider reimbursement.

(d) This section shall not be construed to create a cause of action or remedy that would not exist in the absence of this section, except for the purposes of enforcing the prohibitions set forth in this section.

(e) (1) A managed health insurance issuer shall develop and implement procedures to ensure that health care providers are regularly informed of information maintained by the issuer to evaluate the performance or practice of the health care provider. The issuer shall consult with health care professionals in developing methodologies to collect the health care provider's profiling, tiering, comparison, or ratings data, which may include, but is not limited to, claims data. For those issuers that publicize or otherwise make known to participating providers or their members the results of the provider's performance, the managed health insurance issuer shall, sixty (60) days prior to the public publishing of provider-specific information such as profiling, tiering, performance comparison, including, but not limited to, pay for performance programs or ratings data, do all of the following:

(A) Make available to the provider all methodologies, quality measures, data, analysis, and conclusions, ratings relied upon by the issuer and the degree to which each is relied upon by the issuer and allow the provider a reasonable opportunity to review and provide additional data or medical records and comments on the information proposed to be published by the issuer regarding the individual provider's profiling, tiering, comparison, or ratings;

(B) Should a provider submit additional data or medical records or comments under this subsection (e), that submission shall be made within thirty (30) days of the receipt of notice that the issuer will publish the information. If a provider submits additional data or medical records or comments on the information proposed to be published by the issuer, and the issuer elects to alter the provider's profiling, tiering, comparison, or ratings in accordance with and pursuant to the additional data or medical records and comments, then the issuers shall accordingly modify the provider's profiling, tiering, comparison or ratings prior to public publication of provider-specific information;

(C) The issuer shall provide with the publication of the provider performance rating information a prominently displayed disclosure of the data sources used to develop the rating information, an explanation of the limitations of data derived from these sources, and an explanation of the specific aspects or domains of provider performance that were measured to derive the ratings; and

(D) Whenever the issuer periodically updates any data results or findings publicized pursuant to this section, and to the extent those updates result in a lower rating of the provider's performance rating, the issuer shall repeat the requirements established by subdivisions (e)(1)(A)-(C).

(2) Notwithstanding any law, contract or other legal standard to the contrary, upon satisfying and complying with the requirements of this subsection (e), the issuer may publicize the results of a provider's performance rating in the manner and frequency that the issuer deems appropriate.

History: Acts 1998, ch. 1033, SC 10; 2007, ch. 406, SC 1; T.C.A. SC 56-32-230; Acts 2012, ch. 798, SC 26.