Tenn. Comp. R. & Regs. 0800-02-06-.02 - UTILIZATION REVIEW SYSTEM

(1) This Chapter shall apply to all recommended treatments as defined above for work-related injuries or conditions whenever the recommendation is made after this Chapter, as amended, becomes effective.

(2) Employers shall establish and maintain a system of utilization review. An employer may choose to provide utilization review services itself, through its insurer or through a third party administrator. Whenever utilization review is conducted, whether mandatory under this Chapter, 0800-02-06, or not, such utilization review shall be conducted in complete conformity with this Chapter. Failure to comply with this Chapter in any way may subject the employer and utilization review organization to sanctions and/or civil penalties as set forth in Rule 0800-02-06-.10. The Administrator, the Medical Director or the Court of Workers' Compensation Claims, may determine whether a utilization review was conducted in conformity with this Chapter and may determine that a utilization review is void.

(3) The Administrator may provide or contract for certain utilization review services with a Contractor. The Contractor may provide any service allowed by T.C.A. § 50-6-124, including, but not limited to, reviewing utilization review services and providing peer review. The parties shall cooperate and provide any necessary medical information to the Contractor when requested, which shall not constitute a waiver of any applicable privilege or confidentiality.

(4) Any organization conducting utilization review for workers' compensation cases pursuant to this Chapter shall provide to the Administrator copies of any information provided to the Commissioner of Commerce and Insurance pursuant to T.C.A. § 56-6-704. Any organization conducting utilization review for workers' compensation cases must also register with the Bureau on a form prescribed by the Administrator. Failure to certify to the Commissioner of Commerce and Insurance and be registered with the Bureau prior to performing utilization review services may result in sanctions and/or civil penalties pursuant to Rule 0800-02-06-.10 of this Chapter.

(5) Subject to any applicable requirements of law concerning confidentiality of records, a utilization review organization shall provide the Bureau, including the Medical Director, with any appropriate utilization review records or permit the Bureau to inspect, review, or copy such records in a reasonable manner. The Bureau will maintain any required confidentiality of any personally identifying information concerning employees claiming workers' compensation benefits. Provision of these records pursuant to this rule shall not constitute a waiver of any applicable privilege or confidentiality.

(6) In no event shall an individual concurrently perform case management services, as set forth in Chapter 0800-02-0 7, and utilization review with regard to a single claim of a work -related injury.

(7) Billing and payment for any medical services provided in conjunction with this Chapter shall be subject, as applicable, to the Bureau's Medical Cost Containment Program, Medical Fee Schedule, or In-Patient Hospital Fee Schedule rules contained in Chapters 0800-02-17, 0800-02-18, and 0800-02-19, respectively.

Notes

Tenn. Comp. R. & Regs. 0800-02-06-.02

Original rule filed March 5, 1993; effective April 19, 1993. Amendment filed May 13, 1997; effective July 27, 1997. Amendment filed October 12, 2007; withdrawn December 12, 2007. Repeal and new rule filed August 14, 2009; effective November 12, 2009. Amendment filed December 26, 2013; effective March 26, 2014. Amendments filed October 31, 2016; effective 1/29/2017.

Authority: T.C.A. §§ 50-6-102, 50-6-118, 50-6-124, 50-6-126, 50-6-233, and Public Chapters 282 & 289 (2013).