Tennessee 2025-2026 Regular Session

Tennessee House Bill HB1244 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1
2	2	SENATE BILL 881
3	3	By Reeves
4	4
5	5	HOUSE BILL 1244
6	6	By Martin B
7	7
8	8
9	9	HB1244
10	10	002620
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13	13	AN ACT to amend Tennessee Code Annotated, Title 56,
14	14	relative to pharmacy benefits managers.
15	15
16	16	BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF TENNESSEE:
17	17	SECTION 1. Tennessee Code Annotated, Section 56-7-3110, is amended by adding
18	18	the following at the end of the section immediately preceding the period:
19	19	, subject to § 56-2-305(c)(7)
20	20	SECTION 2. Tennessee Code Annotated, Section 56-2-305(c), is amended by adding
21	21	the following new subdivision:
22	22	(7) Violations made by pharmacy benefits managers as defined in § 56-7-3102.
23	23	SECTION 3. Tennessee Code Annotated, Section 56-7-3102, is amended by adding
24	24	the following as new, appropriately designated subdivisions:
25	25	( ) "Clean claim":
26	26	(A) Means a claim received by a pharmacy benefits manager for
27	27	adjudication that:
28	28	(i) Requires no further information, adjustment, or alteration by
29	29	the provider of the services in order to be processed and paid by the
30	30	pharmacy benefits manager; and
31	31	(ii) Has no defect or impropriety, including a lack of any required
32	32	substantiating documentation or particular circumstance requiring special
33	33	treatment that prevents timely payment from being made on the claim
34	34	under § 56-7-3124;
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39	39	(B) Includes resubmitted paper claims with previously identified
40	40	deficiencies corrected; and
41	41	(C) Does not include:
42	42	(i) A duplicate claim; or
43	43	(ii) A claim submitted more than ninety (90) days after the date of
44	44	service;
45	45	( ) "Duplicate claim" means an original claim and its duplicate, when the
46	46	duplicate is filed within thirty (30) days of the original claim;
47	47	( ) "Pay" means that the pharmacy benefits manager must send the provider
48	48	cash or a cash equivalent in full satisfaction of the allowed portion of the claim, or give
49	49	the provider a credit against any outstanding balance owed by that provider to the
50	50	pharmacy benefits manager. A payment occurs on the date when the cash, cash
51	51	equivalent, or notice of credit is mailed or otherwise sent to the provider;
52	52	( ) "Submitted" means that the provider mails or otherwise sends a claim to the
53	53	pharmacy benefits manager. A submission occurs on the date the claim is mailed or
54	54	otherwise sent to the pharmacy benefits manager;
55	55	SECTION 4. Tennessee Code Annotated, Title 56, Chapter 7, Part 31, is amended by
56	56	adding the following as a new section:
57	57	56-7-3124. Prompt payment standards.
58	58	(a) Not later than thirty (30) calendar days after the date that a pharmacy
59	59	benefits manager receives a claim submitted on paper from a provider, a pharmacy
60	60	benefits manager shall:
61	61	(1) For a clean claim, pay the total covered amount of the claim;
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66	66	(2) Pay the portion of the claim that constitutes a clean claim and that is
67	67	not in dispute and notify the provider in writing why the remaining portion of the
68	68	claim will not be paid; or
69	69	(3) Notify the provider in writing of all reasons why the claim does not
70	70	constitute a clean claim and will not be paid and what substantiating
71	71	documentation and information is required to adjudicate the claim as a clean
72	72	claim.
73	73	(b) Not later than fourteen (14) calendar days after receiving a claim by
74	74	electronic submission, a pharmacy benefits manager shall:
75	75	(1) For a clean claim, pay the total covered amount of the claim;
76	76	(2) Pay the portion of the claim that constitutes a clean claim and that is
77	77	not in dispute and notify the provider why the remaining portion of the claim will
78	78	not be paid; or
79	79	(3) Notify the provider of the reason why the claim does not constitute a
80	80	clean claim and will not be paid and what substantiating documentation or
81	81	information is required to adjudicate the claim.
82	82	(c) A paper claim must not be denied upon resubmission for lack of
83	83	substantiating documentation or information that has been previously provided by the
84	84	healthcare provider.
85	85	(d) A pharmacy benefits manager shall timely provide contracted providers with
86	86	all necessary information to properly submit a claim.
87	87	(e) A pharmacy benefits manager that does not comply with subdivision (b)(1)
88	88	shall pay one percent (1%) interest per month, accruing from the day after the payment
89	89	was due, on that amount of the claim that remains unpaid.
90	90	(f) Regulatory oversight.
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95	95	(1) The commissioner shall ensure, as part of the department's ongoing
96	96	regulatory oversight of pharmacy benefits managers, that pharmacy benefits
97	97	managers properly process and pay claims in accordance with this section.
98	98	(2)
99	99	(A) If the commissioner finds a pharmacy benefits manager has
100	100	failed during any calendar year to properly process and pay ninety-five
101	101	percent (95%) of all clean claims received from all providers during that
102	102	year in accordance with this section, then the commissioner may levy an
103	103	aggregate penalty up to ten thousand dollars ($10,000), if reasonable
104	104	notice in writing is given of the intent to levy the penalty.
105	105	(B) If the commissioner finds a pharmacy benefits manager has
106	106	failed during any calendar year to properly process and pay eighty-five
107	107	percent (85%) of all clean claims received from all providers during that
108	108	year in accordance with this section, then the commissioner may levy an
109	109	aggregate penalty in an amount of not less than ten thousand dollars
110	110	($10,000) nor more than one hundred thousand dollars ($100,000), if
111	111	reasonable notice in writing is given of the intent to levy the penalty.
112	112	(C) If the commissioner finds a pharmacy benefits manager has
113	113	failed during any calendar year to properly process and pay sixty percent
114	114	(60%) of all clean claims received from all providers during that year in
115	115	accordance with this section, then the commissioner may levy an
116	116	aggregate penalty in an amount of not less than one hundred thousand
117	117	dollars ($100,000) nor more than two hundred thousand dollars
118	118	($200,000), if reasonable notice in writing is given of the intent to levy the
119	119	penalty.
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124	124	(D) In determining the amount of any penalty, the commissioner
125	125	shall take into account whether the failure to achieve the standards in this
126	126	section is due to circumstances beyond the pharmacy benefits manager's
127	127	control and whether the pharmacy benefits manager has been in the
128	128	business of processing claims for two (2) years or less.
129	129	(E) The pharmacy benefits manager may request an
130	130	administrative hearing contesting the assessment of any administrative
131	131	penalty imposed by the commissioner within thirty (30) days after receipt
132	132	of the notice of the assessment.
133	133	(3) The commissioner may issue an order directing a pharmacy benefits
134	134	manager or a representative of a pharmacy benefits manager to cease and
135	135	desist from engaging in any act or practice in violation of this section. Within
136	136	fifteen (15) days after service of the cease and desist order, the respondent may
137	137	request a hearing on the question of whether acts or practices in violation of this
138	138	section have occurred.
139	139	(4) All hearings under this part must be conducted pursuant to the
140	140	Uniform Administrative Procedures Act, compiled in title 4, chapter 5.
141	141	(5) In the case of any violations of this section, if the commissioner elects
142	142	not to issue a cease and desist order, or in the event of noncompliance with a
143	143	cease and desist order issued by the commissioner, the commissioner may
144	144	institute a proceeding to obtain injunctive or other appropriate relief in the
145	145	chancery court of Davidson County.
146	146	(6) Examinations to determine compliance with this section may be
147	147	conducted by the commissioner's staff. The commissioner may, if necessary,
148	148	contract with qualified, impartial outside sources to assist in examinations to
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153	153	determine compliance with this section. The expenses of the examinations must
154	154	be assessed against pharmacy benefits managers in accordance with § 56-32-
155	155	115(e). For other pharmacy benefits managers, the commissioner shall bill the
156	156	expenses of the examinations to those entities in accordance with § 56-1-413.
157	157	(g) Rules.
158	158	The commissioner shall adopt rules in accordance with the Uniform
159	159	Administrative Procedures Act, compiled in title 4, chapter 5, to effectuate
160	160	compliance with this section.
161	161	SECTION 5. Tennessee Code Annotated, Section 56-7-3206(c)(3)(A), is amended by
162	162	adding the following new subdivision:
163	163	(vii) Apply the findings from the appeal as to the rate of the reimbursement and
164	164	actual cost for the particular drug or medical product or device to all remaining refills on
165	165	the issued prescription drug or medical product or device, if the reimbursement aligns
166	166	with the appeal.
167	167	SECTION 6. The headings in this act are for reference purposes only and do not
168	168	constitute a part of the law enacted by this act. However, the Tennessee Code Commission is
169	169	requested to include the headings in any compilation or publication containing this act.
170	170	SECTION 7. This act takes effect upon becoming a law, the public welfare requiring it.