Tenn. Comp. R. & Regs. 0800-02-06-.04 - CONTENTS OF UTILIZATION REVIEW REPORT
(1) The utilization
review organization shall communicate its determination to the parties within
the timeframe established in Rule
0800-02-06-.06.
(2) If a utilization review appeal is filed
with the Bureau, any recommended modification in a utilization review report
will be considered a denial for the purpose of evaluating the appeal by the
Bureau.
(3) If the utilization
review determination is a denial of a recommended treatment, then the
utilization review organization shall submit a written utilization review
report in conformity with the requirements of subsection (4) of this Rule. If
the utilization review determination is an approval of a recommended treatment,
then the utilization review organization shall submit written documentation of
the determination; provided that the written documentation is not required to
be a utilization review report in conformity with the requirements of
subsection (4) of this Rule. A utilization review report and other written
documentation may be communicated through electronic means when available and
appropriate.
(4) The utilization
review organization physician's determination report shall contain a list of
all medical information reviewed, the assessment of those records, the basis of
the determination in accordance with the Bureau's adopted Treatment Guidelines,
and the name and credentials of the utilization review physician. This
information shall be sent to all parties. The utilization review communication
to the authorized treating physician shall separately contain the information
necessary for a peer-to-peer telephonic conference, or instructions on
accessing an electronic portal for secure electronic communication between the
utilization review physician and the authorized treating physician. This
information shall be sent to the authorized treating physician and copied to
the employer as defined in these rules.
(5) The utilization review determination
report shall include an attestation statement and the signature of the
utilization review physician that the physician has personally reviewed the
list of medical information reviewed and made the determination. It shall
include the utilization review physician's Tennessee license number, board
certification, information and any other appropriate credential that supports
the qualification of the physician.
(6) The utilization review report shall
adhere to the following requirements:
(a) The
utilization review organization shall consider only the medical necessity,
appropriateness, efficiency, and quality of the recommended treatment for the
employee's condition. The consideration under quality may include factors such
as timeliness, effectiveness, efficacy, conformity to the Bureau's adopted
Treatment Guidelines, and other evidence-based treatment guidelines (including
the comments and observations) approved by the Administrator. Treatment
recommendations shall not be denied if they follow the Bureau's adopted
Treatment Guidelines.
(b) Whenever
a utilization review organization determines that the recommended treatment
will be denied, the utilization review report must contain specific and
detailed reasons for the denial, a listing of all the documents used to make
the determination, and a record of any other communication between the
utilization review physician and the requesting provider.
(c) The utilization review organization shall
also include the name, address, and appropriate contact number or email address
of the utilization review physician making a denial determination.
(d) All utilization review reports that deny
or modify any portion of a recommended treatment, including medications, shall
include an appeal form prescribed by the Bureau. The utilization review
organization shall transmit a copy of the utilization review report and appeal
form to the authorized treating physician, employee, and employer. Upon
request, the utilization review organization shall transmit any utilization
review report to the Bureau. Failure to include the appeal form in the
utilization review report and transmit such to all parties may result in
sanctions and/or civil penalties pursuant to Rule
0800-02-06-.10
of this Chapter.
Notes
Authority: T.C.A. ยงยง 50-6-102, 50-6-118, 50-6-124, 50-6-126, and 50-6-233.
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