Bill > SB2020

This bill aims to reform health insurance practices in Tennessee by prohibiting health insurance entities from "downcoding" (adjusting a claim to a lower reimbursement code) unless specific conditions are met, such as a review by a physician of similar specialty and a documented clinical review of the patient's medical record, with clear notification to the healthcare provider about the reasons for the adjustment and their right to appeal. The bill also introduces protections for patients with chronic conditions, clarifies prior authorization rules, and restricts the use of artificial intelligence (AI) tools in claim denials, stating that adverse determinations must be made by a licensed physician after reviewing all relevant clinical information, not solely by an automated system. Furthermore, it establishes new rules for prompt payment of claims, including shorter timelines for electronic submissions, and addresses fees associated with electronic payments to healthcare providers, while also requiring health insurance contracts to consider a patient's medical complexity and co-morbidity in reimbursement policies. The bill also mandates regular audits of health insurance entities to ensure compliance with these new regulations and outlines enforcement mechanisms, including civil penalties and a requirement for health insurance entities to pay a 25% penalty on unpaid downcoded claims.

https://wapp.capitol.tn.gov/apps/Billinfo/default.aspx?BillNumber=SB2020&ga=114