Tennessee 2025-2026 Regular Session

Tennessee Senate Bill SB0881 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
1	1
2		-	HOUSE BILL 1244
3		-	By Martin B
	2	+	<BillNo> <Sponsor>
4	3
5	4		SENATE BILL 881
6	5		By Reeves
7	6
8	7
9	8		SB0881
10	9		002620
11	10		- 1 -
12	11
13	12		AN ACT to amend Tennessee Code Annotated, Title 56,
14	13		relative to pharmacy benefits managers.
15	14
16	15		BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF TENNESSEE:
17	16		SECTION 1. Tennessee Code Annotated, Section 56-7-3110, is amended by adding
18	17		the following at the end of the section immediately preceding the period:
19	18		, subject to § 56-2-305(c)(7)
20	19		SECTION 2. Tennessee Code Annotated, Section 56-2-305(c), is amended by adding
21	20		the following new subdivision:
22	21		(7) Violations made by pharmacy benefits managers as defined in § 56-7-3102.
23	22		SECTION 3. Tennessee Code Annotated, Section 56-7-3102, is amended by adding
24	23		the following as new, appropriately designated subdivisions:
25	24		( ) "Clean claim":
26	25		(A) Means a claim received by a pharmacy benefits manager for
27	26		adjudication that:
28	27		(i) Requires no further information, adjustment, or alteration by
29	28		the provider of the services in order to be processed and paid by the
30	29		pharmacy benefits manager; and
31	30		(ii) Has no defect or impropriety, including a lack of any required
32	31		substantiating documentation or particular circumstance requiring special
33	32		treatment that prevents timely payment from being made on the claim
34	33		under § 56-7-3124;
	34	+	(B) Includes resubmitted paper claims with previously identified
	35	+	deficiencies corrected; and
35	36
36	37
37	38		- 2 - 002620
38	39
39		-	(B) Includes resubmitted paper claims with previously identified
40		-	deficiencies corrected; and
41	40		(C) Does not include:
42	41		(i) A duplicate claim; or
43	42		(ii) A claim submitted more than ninety (90) days after the date of
44	43		service;
45	44		( ) "Duplicate claim" means an original claim and its duplicate, when the
46	45		duplicate is filed within thirty (30) days of the original claim;
47	46		( ) "Pay" means that the pharmacy benefits manager must send the provider
48	47		cash or a cash equivalent in full satisfaction of the allowed portion of the claim, or give
49	48		the provider a credit against any outstanding balance owed by that provider to the
50	49		pharmacy benefits manager. A payment occurs on the date when the cash, cash
51	50		equivalent, or notice of credit is mailed or otherwise sent to the provider;
52	51		( ) "Submitted" means that the provider mails or otherwise sends a claim to the
53	52		pharmacy benefits manager. A submission occurs on the date the claim is mailed or
54	53		otherwise sent to the pharmacy benefits manager;
55	54		SECTION 4. Tennessee Code Annotated, Title 56, Chapter 7, Part 31, is amended by
56	55		adding the following as a new section:
57	56		56-7-3124. Prompt payment standards.
58	57		(a) Not later than thirty (30) calendar days after the date that a pharmacy
59	58		benefits manager receives a claim submitted on paper from a provider, a pharmacy
60	59		benefits manager shall:
61	60		(1) For a clean claim, pay the total covered amount of the claim;
	61	+	(2) Pay the portion of the claim that constitutes a clean claim and that is
	62	+	not in dispute and notify the provider in writing why the remaining portion of the
	63	+	claim will not be paid; or
62	64
63	65
64	66		- 3 - 002620
65	67
66		-	(2) Pay the portion of the claim that constitutes a clean claim and that is
67		-	not in dispute and notify the provider in writing why the remaining portion of the
68		-	claim will not be paid; or
69	68		(3) Notify the provider in writing of all reasons why the claim does not
70	69		constitute a clean claim and will not be paid and what substantiating
71	70		documentation and information is required to adjudicate the claim as a clean
72	71		claim.
73	72		(b) Not later than fourteen (14) calendar days after receiving a claim by
74	73		electronic submission, a pharmacy benefits manager shall:
75	74		(1) For a clean claim, pay the total covered amount of the claim;
76	75		(2) Pay the portion of the claim that constitutes a clean claim and that is
77	76		not in dispute and notify the provider why the remaining portion of the claim will
78	77		not be paid; or
79	78		(3) Notify the provider of the reason why the claim does not constitute a
80	79		clean claim and will not be paid and what substantiating documentation or
81	80		information is required to adjudicate the claim.
82	81		(c) A paper claim must not be denied upon resubmission for lack of
83	82		substantiating documentation or information that has been previously provided by the
84	83		healthcare provider.
85	84		(d) A pharmacy benefits manager shall timely provide contracted providers with
86	85		all necessary information to properly submit a claim.
87	86		(e) A pharmacy benefits manager that does not comply with subdivision (b)(1)
88	87		shall pay one percent (1%) interest per month, accruing from the day after the payment
89	88		was due, on that amount of the claim that remains unpaid.
90	89		(f) Regulatory oversight.
	90	+	(1) The commissioner shall ensure, as part of the department's ongoing
	91	+	regulatory oversight of pharmacy benefits managers, that pharmacy benefits
	92	+	managers properly process and pay claims in accordance with this section.
91	93
92	94
93	95		- 4 - 002620
94	96
95		-	(1) The commissioner shall ensure, as part of the department's ongoing
96		-	regulatory oversight of pharmacy benefits managers, that pharmacy benefits
97		-	managers properly process and pay claims in accordance with this section.
98	97		(2)
99	98		(A) If the commissioner finds a pharmacy benefits manager has
100	99		failed during any calendar year to properly process and pay ninety-five
101	100		percent (95%) of all clean claims received from all providers during that
102	101		year in accordance with this section, then the commissioner may levy an
103	102		aggregate penalty up to ten thousand dollars ($10,000), if reasonable
104	103		notice in writing is given of the intent to levy the penalty.
105	104		(B) If the commissioner finds a pharmacy benefits manager has
106	105		failed during any calendar year to properly process and pay eighty-five
107	106		percent (85%) of all clean claims received from all providers during that
108	107		year in accordance with this section, then the commissioner may levy an
109	108		aggregate penalty in an amount of not less than ten thousand dollars
110	109		($10,000) nor more than one hundred thousand dollars ($100,000), if
111	110		reasonable notice in writing is given of the intent to levy the penalty.
112	111		(C) If the commissioner finds a pharmacy benefits manager has
113	112		failed during any calendar year to properly process and pay sixty percent
114	113		(60%) of all clean claims received from all providers during that year in
115	114		accordance with this section, then the commissioner may levy an
116	115		aggregate penalty in an amount of not less than one hundred thousand
117	116		dollars ($100,000) nor more than two hundred thousand dollars
118	117		($200,000), if reasonable notice in writing is given of the intent to levy the
119	118		penalty.
	119	+	(D) In determining the amount of any penalty, the commissioner
	120	+	shall take into account whether the failure to achieve the standards in this
	121	+	section is due to circumstances beyond the pharmacy benefits manager's
120	122
121	123
122	124		- 5 - 002620
123	125
124		-	(D) In determining the amount of any penalty, the commissioner
125		-	shall take into account whether the failure to achieve the standards in this
126		-	section is due to circumstances beyond the pharmacy benefits manager's
127	126		control and whether the pharmacy benefits manager has been in the
128	127		business of processing claims for two (2) years or less.
129	128		(E) The pharmacy benefits manager may request an
130	129		administrative hearing contesting the assessment of any administrative
131	130		penalty imposed by the commissioner within thirty (30) days after receipt
132	131		of the notice of the assessment.
133	132		(3) The commissioner may issue an order directing a pharmacy benefits
134	133		manager or a representative of a pharmacy benefits manager to cease and
135	134		desist from engaging in any act or practice in violation of this section. Within
136	135		fifteen (15) days after service of the cease and desist order, the respondent may
137	136		request a hearing on the question of whether acts or practices in violation of this
138	137		section have occurred.
139	138		(4) All hearings under this part must be conducted pursuant to the
140	139		Uniform Administrative Procedures Act, compiled in title 4, chapter 5.
141	140		(5) In the case of any violations of this section, if the commissioner elects
142	141		not to issue a cease and desist order, or in the event of noncompliance with a
143	142		cease and desist order issued by the commissioner, the commissioner may
144	143		institute a proceeding to obtain injunctive or other appropriate relief in the
145	144		chancery court of Davidson County.
146	145		(6) Examinations to determine compliance with this section may be
147	146		conducted by the commissioner's staff. The commissioner may, if necessary,
148	147		contract with qualified, impartial outside sources to assist in examinations to
	148	+	determine compliance with this section. The expenses of the examinations must
	149	+	be assessed against pharmacy benefits managers in accordance with § 56-32-
149	150
150	151
151	152		- 6 - 002620
152	153
153		-	determine compliance with this section. The expenses of the examinations must
154		-	be assessed against pharmacy benefits managers in accordance with § 56-32-
155	154		115(e). For other pharmacy benefits managers, the commissioner shall bill the
156	155		expenses of the examinations to those entities in accordance with § 56-1-413.
157	156		(g) Rules.
158	157		The commissioner shall adopt rules in accordance with the Uniform
159	158		Administrative Procedures Act, compiled in title 4, chapter 5, to effectuate
160	159		compliance with this section.
161	160		SECTION 5. Tennessee Code Annotated, Section 56-7-3206(c)(3)(A), is amended by
162	161		adding the following new subdivision:
163	162		(vii) Apply the findings from the appeal as to the rate of the reimbursement and
164	163		actual cost for the particular drug or medical product or device to all remaining refills on
165	164		the issued prescription drug or medical product or device, if the reimbursement aligns
166	165		with the appeal.
167	166		SECTION 6. The headings in this act are for reference purposes only and do not
168	167		constitute a part of the law enacted by this act. However, the Tennessee Code Commission is
169	168		requested to include the headings in any compilation or publication containing this act.
170	169		SECTION 7. This act takes effect upon becoming a law, the public welfare requiring it.