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HOUSE BILL 2619
By Howell
SENATE BILL 2155
By Watson
SB2155
012008
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AN ACT to amend Tennessee Code Annotated, Title 4;
Title 8; Title 56 and Title 71, relative to insurance.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF TENNESSEE:
SECTION 1. Tennessee Code Annotated, Title 56, Chapter 7, is amended by adding
the following as a new part:
56-7-3901.
As used in this part:
(1) "Artificial intelligence" means a machine-based system that:
(A) Can, for a given set of human-defined objectives, make
predictions, recommendations, or decisions; influence real and virtual
environments without significant human oversight; or that can learn from
experience in an automated manner and improve such performance
when exposed to data sets; or
(B) Is developed in any context, including software or physical
hardware, and solves tasks requiring human-like perception, cognition,
planning, learning, communication, or physical action;
(2) "Commission" means the Tennessee commission of insurance
review, created pursuant to § 56-7-3902;
(3) "Covered individual" means an individual who is covered by a health
benefit plan;
(4) "Covered services" means medical services for which a
reimbursement is available under the enrollee's plan contract, or for which a
reimbursement would be available but for the application of contractual
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limitations such as deductibles, copayments, coinsurance, waiting periods,
annual or lifetime maximums, frequency limitations, alternative benefits
payments, or any other limitation;
(5) "Downcoding" means the adjustment of a claim submitted to a health
benefit plan to a less complex or lower cost procedure code;
(6) "Fee schedule" means a list of reimbursement amounts assigned to
specific codes and used by a health insurance entity pursuant to a contract
between a health insurance entity and a healthcare provider to calculate
payments paid to the provider for healthcare services delivered to enrollees;
(7) "Health benefit plan":
(A) Means benefits consisting of medical care, provided directly,
through insurance or reimbursement, or otherwise and including items
and services paid for as medical care, under any policy, certificate, or
agreement offered by a health insurance entity; and
(B) Does not include policies or certificates covering only
accident, credit, disability income, long-term care, hospital indemnity,
medicare supplement as defined in § 1882(g)(1) of the Social Security Act
(42 U.S.C. § 1395ss(g)(1)), specified disease, other limited benefit health
insurance, automobile medical payment insurance, or insurance under
which benefits are payable with or without regard to fault and that are
statutorily required to be contained in any liability insurance policy or
equivalent self-insurance;
(8) "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 a health benefit plan,
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including, but not limited to, an insurance company, a health maintenance
organization, and a nonprofit hospital and medical service corporation;
(9) "Healthcare provider" means healthcare professionals,
establishments, or facilities licensed, registered, certified, or permitted pursuant
to title 63 or title 68 and regulated either under the authority of the department of
health or any agency, board, council, or committee attached to the department of
health;
(10) "Lasering" means the practice of assigning a higher attachment
point or deductible, or denying coverage, for a covered individual or group of
covered individuals within the policy's coverage who have a known, high-cost
medical condition or history of significant claims;
(11) "Material change" means a change to:
(A) A health benefit plan's rules, guidelines, policies, or
procedures concerning payment for medical services;
(B) The general practices of the health benefit plan that decrease
reimbursements paid to providers; or
(C) How a health benefit plan adjudicates and pays claims for
services if the change would:
(i) Require a provider to change how the provider submits
claims to the plan; or
(ii) Increase the provider's administrative expense;
(12) "Participating provider" or "provider" means a healthcare provider
who provides healthcare services to a covered individual at a fee set by or at a
fee subject to the approval of an insurer, health services plan, third-party
administrator, or another party that contracts to provide healthcare services; and
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(13) "Person" means an individual, organization, trust, foundation, group,
association, partnership, limited liability company, corporation, society, or any
other entity.
56-7-3902.
(a) There is created the Tennessee commission of insurance review for the
purpose of reviewing complaints related to and enforcing the requirements of this part.
The commission consists of seven (7) members as follows:
(1) The commissioner of health, or the commissioner's designee, who
serves as chair;
(2) One (1) member, appointed by the speaker of the house of
representatives, with no less than five (5) years' experience as a healthcare
professional;
(3) One (1) member, appointed by the speaker of the senate, with no
less than five (5) years' experience in the health insurance industry;
(4) Two (2) members of the house of representatives, appointed by the
speaker of the house of representatives; and
(5) Two (2) members of the senate, appointed by the speaker of the
senate.
(b)
(1) To stagger the terms of the newly appointed commission members,
the appointing authorities shall make initial appointments as follows:
(A) The member appointed under subdivision (a)(2) is appointed
to a three-year term, which expires on June 30, 2029; and
(B) The member appointed under subdivision (a)(3) is appointed
to a four-year term, which expires on June 30, 2030.
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(2) Following the expiration of members' initial terms as prescribed in
subdivision (b)(1), all appointments to the commission shall be for terms of four
(4) years and shall begin on July 1 and expire on June 30, four (4) years
thereafter.
(3) Legislative members of the commission appointed under subdivisions
(a)(4) and (5) serve terms of two (2) years and may be reappointed for one (1)
additional two-year term, with both terms running commensurate with their
service as members of the general assembly.
(4) Members appointed under subdivisions (a)(2)-(5) continue to serve
until a successor has been appointed.
(5) Vacancies occurring for members appointed under subdivisions
(a)(2)-(5), other than through the expiration of terms, are filled for the remainder
of the term of the member being replaced.
(6) Commission members described in subdivisions (a)(2) and (3) are
eligible for reappointment, but do not succeed themselves automatically.
(7) Appointments to the commission for the remainder of an unexpired
term and reappointments must be made in the same manner as under
subdivisions (a)(2)-(5).
(c) Each member of the commission described in subdivisions (a)(2)-(5) is
entitled to receive reimbursement for the member's traveling and other necessary
expenses actually incurred while engaged in the performance of any official duties when
so authorized by the commission, but such expenses must be made in accordance with
the comprehensive state travel regulations duly promulgated by the commissioner of
finance and administration and approved by the attorney general and reporter.
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(d) A majority of the commission constitutes a quorum, and the concurrence of a
majority of those present and voting on a matter is required for a determination of
matters within the commission's jurisdiction.
(e) The commission is to be funded from the general fund as appropriated
annually in the general appropriations act, with such funding to be included for, but not
limited to, the commission's administrative costs, hiring of staff necessary to carry out
the commission's duties, and for costs of any programs in support of the purposes for
which the commission is organized. The commission may also be financed through
private funding and through public and private grants.
56-7-3903.
(a) The commission has the power and authority to:
(1) Adopt, modify, repeal, promulgate, and enforce rules for:
(A) The conduct of the affairs of the commission;
(B) Enforcement of the commission's orders; and
(C) Otherwise effectuating this part;
(2) Issue subpoenas requiring the attendance of witnesses and
production of such evidence as requested, administer oaths, and take such
testimony as the commission deems necessary in fulfilling its purpose. If a
person refuses to obey a subpoena issued by the commission under this part,
then the chancery court of Wilson County has jurisdiction upon application of the
commission to issue an order requiring the person to appear and testify or
produce evidence as the case may require, and a failure to obey the order of the
court may be punished by the court as contempt;
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(3) Offer advisory technical assistance to a health insurance entity or
participating provider regarding appropriate claim or code review practices, to the
extent it may be competently offered;
(4) Order remedial actions regarding violations of this part, including
health insurance entity coding or claim practices; and
(5) Exercise all the powers and take all the actions necessary, proper, or
convenient for the accomplishment of the purposes enumerated in this part.
(b)
(1) In addition to the powers described under subsection (a), the
commission shall review and conduct informal hearings of complaints submitted
to it regarding violations of this part.
(2) A complainant to the Tennessee commission of insurance review
shall first appeal or make a complaint through the standard claim appeal process,
or utilize any other available remedy offered by the health insurance entity, prior
to seeking an informal hearing before the commission.
(3) The commission shall consider the reasonableness of the health
insurance entity's claim or code review practices and policies, use of such review
practices in connection with the submitted complaint, and other evidence
presented during the hearing, if applicable, in making the commission's decision.
(4) The request for an informal hearing under this subsection (b) must be
received within thirty (30) days of the final adverse decision of the health
insurance entity.
(5) Appellate review of the commission's decisions is governed by the
Uniform Administrative Procedures Act, compiled in title 4, chapter 5. The
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Wilson County chancery court has jurisdiction over judicial review of the
commission's decisions.
(6) In the conduct of an informal hearing upon complaint, the commission
may receive affidavit evidence, in addition to transcripts and other evidence of
actions by the health insurance entity or participating provider, and may render
its decision on the basis of that evidence or, if the commission deems an open
hearing appropriate, may order the interested parties be notified of the date, time,
and place that such hearing will be held.
(7) The commission may:
(A) Order such remedial actions as necessary to address a
participating provider's complaint, including the exercise of any authority
conferred upon the commission by this part; and
(B) Request that the attorney general and reporter bring an action
in a court of competent jurisdiction in the name of the state against an
individual or entity for violations of this part.
(8) Commission staff may consolidate complaints that raise substantially
similar issues against the same health insurance entity to be heard together
before the commission.
(c) The commission may participate by electronic or other means of
communication for the benefit of the public and the commission in connection with any
meeting authorized by law.
56-7-3904.
(a) A health insurance entity shall not offer or maintain in this state a health
benefit plan that based on the participating provider's contracted fee for covered services
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uses downcoding in a manner that prevents the provider from collecting the fee for
actual services performed either from the health benefit plan or the patient.
(b)
(1) Except as provided in subdivision (b)(2), a health insurance entity
shall not offer or maintain in this state a health benefit plan that allows the health
insurance entity to:
(A) Make material changes to the health benefit plan, including by
changing a provider's fee schedule, a provider manual, or a
reimbursement rule or policy, without:
(i) Providing at least sixty (60) days' notice and an
opportunity to negotiate the changes to the affected provider; and
(ii) Allowing an affected provider to terminate the
provider's contract with the health insurance entity without penalty
if the health insurance entity and the affected provider do not
come to an agreement regarding the proposed changes to the
health benefit plan; or
(B) Otherwise unilaterally make changes to the contract between
the health insurance entity and a provider.
(2) Subdivision (b)(1) does not apply to the following changes to a health
benefit plan:
(A) Any change in a provider's fee schedule due to a change
effected by the federal or state government to its healthcare fee schedule,
if the provider and health insurance carrier have previously agreed that
the provider's fee schedule is based on a percentage or some other
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formula of a current government healthcare fee schedule, such as
medicare;
(B) Any change in a provider's reimbursement for drugs,
immunizations, injectables, supplies, or devices if the provider and health
insurance carrier or pharmacy benefits manager, as defined by § 56-7-
3102, have previously agreed that any reimbursement for drugs,
immunizations, injectables, supplies, or devices will be based on a
percentage, or some other formula, of a price index not established by the
health insurance carrier, such as the average wholesale price or average
sales price;
(C) Any changes in the provider's reimbursement for drugs,
immunizations, injectables, supplies, or devices if the provider and the
health insurance carrier or pharmacy benefits manager, as defined in §
56-7-3102, have previously agreed to any reimbursement for drugs,
immunizations, injectables, supplies, or devices in accordance with § 56-
7-3104 and based upon maximum allowable cost pricing as regulated by
§§ 56-7-3101 and 56-7-3106;
(D) Any change to Current Procedural Terminology (CPT) codes,
Healthcare Common Procedure Coding System (HCPCS) codes,
International Statistical Classification of Disease and Related Health
Problems (ICD) Codes, or other coding sets recognized or used by the
centers for medicare and medicaid services (CMS) that a health
insurance carrier utilized in creating a provider's fee schedule;
(E) Any change to revenue codes as established by the National
Uniform Billing Committee (NUBC);
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(F) Any changes in a provider's fee schedule due to one (1) or
more of the following if previously agreed to in a provider's agreement
with a health insurance carrier:
(i) Payments made to the healthcare provider by the
health insurance carrier or payments made to the health insurance
carrier by the provider that are based on values or quality
measures explicitly described in the written agreement between
the provider and the health insurance carrier intended to improve
care provided to the health insurance carrier's members;
(ii) Escalator or de-escalator clauses;
(iii) Provisions that require adjustments to payment due to
population health management performance or results; or
(iv) Any arrangements, initiatives, or value-based
payments relating to or resulting from the implementation or
operation of the Tennessee Health Care Innovation Initiative or
any successor state program applicable to provider agreements
covered by this section; or
(G) Changes in standard codes and guidelines developed by the
American Medical Association or a similar organization.
56-7-3905.
A health insurance entity shall not:
(1) Send an enrollee's medical information or history to a person located
outside of the United States for any purpose, including the review of claims
submitted by a healthcare provider; or
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(2) Enter into or renew a contract with a person that authorizes or
requires the health insurance entity to send an enrollee's medical information or
history to a person located outside of the United States for any purpose.
56-7-3906.
A health insurance entity shall ensure that coding or claim reviews that are
conducted using artificial intelligence are reviewed, approved, or sent for further review
by a human healthcare provider reviewer prior to the health insurance entity sending a
determination to the participating provider who submitted the claim or the covered
individual for whom the services underlying the submitted claim were performed. The
healthcare provider who reviews and approves a coding or claim review conducted by
artificial intelligence must have relevant experience in the healthcare field to which the
code or claim being reviewed relates.
56-7-3907.
A health insurance entity shall not remove an enrollee from a group or group plan
if the enrollee was covered the prior year in the same group or group plan, except:
(1) For nonpayment of the required premiums by the policyholder or
contract holder;
(2) For fraud or misrepresentation of the policyholder or contract holder
or, with respect to coverage of individual enrollees, the enrollee or the enrollee's
representative; or
(3) When the number of enrollees covered under the plan is fewer than
the number of insureds or percentage of enrollees required by participation
requirements under the plan, if applicable.
56-7-3908.
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A health insurance entity shall not use lasering when underwriting a stop-loss
plan for a health benefit plan offered in this state.
56-7-3909.
(a) On or after July 1, 2026, a person shall not directly or indirectly own, operate,
or control the whole or any part of a healthcare provider in this state, including through
investment interests, while the person also directly or indirectly owns, operates, or
controls the whole or any part of a health insurance entity, including through investment
interests.
(b) If a person directly or indirectly owns, operates, or controls the whole or any
part of both a healthcare provider and a health insurance entity prior to July 1, 2026,
then the person shall:
(1) Not require a covered individual to utilize a healthcare provider over
which the person has such direct or indirect ownership or control; provided, that
this subsection (b) does not prohibit the inclusion of such healthcare entity or
provider as an available option to the covered individual if the covered individual
is given additional choices of similar quality; and
(2) If the person is negotiating with the state to provide a plan managed
by the health care finance and administration division of the department of
finance and administration or a successor division or department, or the group
insurance plans offered under title 8, chapter 27, disclose such ownership,
operation, or control.
56-7-3910.
(a) A participating provider or covered individual who believes a health insurance
entity has violated this part may submit a complaint to the Tennessee commission of
insurance review.
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(b)
(1) In addition to the remedy described in subsection (a), upon request
by the Tennessee commission of insurance review or receipt by the attorney
general and reporter of other relevant information, the attorney general and
reporter may bring an action in a court of competent jurisdiction in the name of
the state against an individual or entity relative to a violation of this part. In a
cause of action brought by the attorney general and reporter pursuant to this
subdivision (b)(1), the court may:
(A) Issue orders and injunctions to restrain and prevent violations
of this section;
(B) Impose compensatory and punitive damages; and
(C) Order reasonable attorney fees and investigative costs be
paid by the violator to the state.
(2) An action brought by the attorney general and reporter pursuant to
subdivision (b)(1) may also include other causes of action.
56-7-3911.
Notwithstanding another law to the contrary, including § 56-7-1010, and except
as provided under § 56-7-3910(b), the commission has exclusive enforcement authority
of this part.
56-7-3912.
(a) The department of commerce and insurance and its employees shall fully
cooperate with the commission in the execution of this part by timely providing requested
information and sharing relevant documents and data.
(b) The transfer or sharing of documents, data, records, or other information
pursuant to this section does not waive an applicable privilege from disclosure.
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SECTION 2. Tennessee Code Annotated, Section 4-29-249(a), is amended by adding
the following as a new subdivision:
( ) Tennessee commission of insurance review, created by § 56-7-3902;
SECTION 3. Tennessee Code Annotated, Section 56-7-1013(c), is amended by
deleting subdivisions (1) and (3).
SECTION 4. Tennessee Code Annotated, Section 56-7-1013, is amended by deleting
subsection (g).
SECTION 5. Tennessee Code Annotated, Section 56-7-3302, is amended by deleting
the section.
SECTION 6. Tennessee Code Annotated, Title 56, Chapter 7, Part 10, is amended by
adding the following as a new section:
(a) If a covered service is within the scope of practice of a provider with a
particular license classification and a health insurance entity provides reimbursement for
that service when performed by a provider with a different license classification, the
health insurance entity shall not deny reimbursement or pay a different reimbursement
rate to a provider with a different license classification, regardless of the billing modifier
or coding designation used to identify the provider of the service.
(b) A health insurance entity shall not establish or apply a different fee schedule,
reimbursement methodology, conversion factor, unit valuation, payment adjustment,
site-of-service differential, or code restriction, solely on the basis of the healthcare
provider's licensure classification being different from the classification of a medical
doctor or osteopathic physician. This subsection (b) regulates health insurance entity
practices as part of the business of insurance and does not apply to any plan or
arrangement governed by the Employee Retirement Income Security Act of 1974
(ERISA) (29 U.S.C. § 1001 et seq.), including, but not limited to, self-funded or self-
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insured employer-sponsored health plans. This subsection (b) is intended to fall within
the scope of ERISA § 514(b)(2)(A) as a law that regulates insurance.
(c) A health insurance entity shall not implement or enforce reimbursement
provisions that are less favorable for healthcare providers licensed under a different
profession when performing the same or substantially similar services within their lawful
scope of practice.
(d) This section does not expand a provider's scope of practice or require a
health insurance entity to contract with a particular provider.
(e) A health insurance entity shall not reduce reimbursement rates for physicians
or other providers for the purpose or effect of avoiding compliance with the requirements
of this section.
SECTION 7. All rules and regulations issued or promulgated by the department of
commerce and insurance that relate to the functions, duties, and responsibilities of the
Tennessee commission of insurance review are transferred to the commission, to be
administered and enforced by the commission on the effective date of this act.
SECTION 8. This act takes effect July 1, 2026, the public welfare requiring it, and
applies to conduct occurring on or after that date.