Senate Bill 881 aims to amend the Tennessee Code Annotated regarding the operations of pharmacy benefits managers (PBMs). The bill introduces new definitions, including "clean claim," "duplicate claim," "pay," and "submitted," which clarify the criteria for claims processing and payment. It establishes prompt payment standards, requiring PBMs to pay clean claims within specified timeframes—30 days for paper submissions and 14 days for electronic submissions. Additionally, the bill mandates that PBMs must provide timely notifications to providers regarding claims that are not paid, including reasons for denial and necessary documentation for adjudication.

Furthermore, the bill introduces penalties for PBMs that fail to meet the established standards for processing clean claims. If a PBM does not properly process and pay a certain percentage of clean claims, the commissioner may impose financial penalties ranging from $10,000 to $200,000, depending on the severity of the violations. The bill also allows for administrative hearings to contest penalties and provides the commissioner with the authority to issue cease and desist orders for violations. Overall, Senate Bill 881 seeks to enhance accountability and efficiency in the claims processing practices of pharmacy benefits managers in Tennessee.

Statutes affected:
Introduced: 56-7-3110, 56-2-305(c), 56-2-305, 56-7-3102, 56-7-3206(c)(3)(A), 56-7-3206