Tenn. Comp. R. & Regs. 0800-02-06-.06 - TIME REQUIREMENTS
(1) If a
recommended treatment requires utilization review, then an employer shall
submit the case to its utilization review organization within four (4) business
days of the authorized treating physician's notification of the recommended
treatment, subject to subsection (5) of this Rule. The four (4) business day
interval begins when the adjuster receives the medical record that corresponds
in time to the date of the treatment request. The authorized treating
physician's notification of the recommended treatment to the employer shall, at
a minimum, be in a form that confirms transmission by showing the time and date
of receipt (e.g., facsimile). The employer shall notify all parties upon
submitting the case to its utilization review organization and shall also, if
requested, notify the Bureau. If the employer fails to comply with this
subsection, then the employer may be subject to sanctions and/or civil
penalties pursuant to Rule
0800-02-06-.10
of this Chapter.
(2) The adjuster
shall respond to the requesting provider within four (4) business days of a
receipt of a request for treatment, referral, second opinion, or consult. The
four (4) business day interval begins when the adjuster receives the medical
record that corresponds in time to the date of the treatment request. If the
adjuster does not approve the request within four (4) business days, the
adjuster shall immediately send the request to the utilization review
organization and notify all parties. The adjuster shall send to the utilization
review organization all pertinent medical records corresponding to tests or
treatments paid for by the insurer in the past twelve (12) months and any
communications necessary for the utilization review organization to complete
its determination. This shall include but not be limited to the Form C35-A
containing current and complete information of the employer, the names and
contact information for the injured worker, the adjuster, the adjuster's
supervisor, the compliance contact, and the attorneys. If there is no existing
compliance contact email, the email for the adjuster's supervisor, the office
manager or other liaison shall be listed. The medical records shall be in
chronological or reverse chronological order, free of duplicates, one-sided,
free of fax confirmation sheets and free of billing statements. The
organization of the medical records may be accomplished by the utilization
review organization. The employer may be subject to sanctions and/or civil
penalties pursuant to Rule
0800-02-06-.10
of this Chapter.
(3) The
utilization review organization shall render the determination and communicate
the determination in writing to the authorized treating physician, employee and
employer within seven (7) business days of receipt of the case from the
employer, subject to subsection (5) of this Rule. If the determination is a
denial, the utilization review report shall list all records and supplemental
material reviewed by the utilization review organization. Upon request, the
authorized treating physician or employee may obtain copies of any such records
and supplemental material reviewed by the utilization review organization. The
utilization review report shall also include an appeal form prescribed by the
Bureau on which the utilization review organization shall identify the state
file number associated with the claim for which treatment is being recommended,
if any, and shall identify the utilization review organization's certification
number issued by the Bureau. If the utilization review organization fails to
comply with this subsection, then the utilization review organization may be
subject to sanctions and/or civil penalties pursuant to Rule
0800-02-06-.10
of this Chapter.
(4) If a denial of
the recommended treatment is appealed to the Bureau, then the employer as
defined in these rules shall send a copy of the utilization review report and
all records reviewed by the utilization review organization to the Bureau
within five (5) business days of a request from the Bureau.
(5) When the adjuster receives notification
of an appeal being filed with the Bureau, the adjuster shall send to the
Bureau, within (5) five business days, the same records as sent to the
utilization review organization, including the medical records for the past
twelve (12) months, the complete and current Form C35-A and the utilization
review organization determination report, including the utilization review
physician's report containing the medical rationale for the denial. These shall
be sent to the Bureau without duplicates or billing and fax records and in
chronological or reverse chronological order, one-sided, containing the medical
records, diagnostic studies, and medical correspondence for one calendar year
before the date of the denial/modification determination. These record
requirements may be met by sending the documents that were reorganized by the
utilization review organization. The employer may be subject to sanctions
and/or civil penalties pursuant to Rule
0800-02-06-.10
of this Chapter.
(6) An approval of
a recommended treatment by the employer's utilization review organization shall
be final and binding on the parties for administrative purposes.
(7) When there is a dispute over a request
for information, the following timeframes shall apply:
(a) If the employer or utilization review
organization does not possess all necessary information in order to evaluate
the recommended treatment and render the utilization review determination, then
it shall immediately make a written request for such information to the
authorized treating physician, who shall comply with the written request within
five business days of receipt of the written request. The time requirements in
subsections (1)-(2) of this Rule shall be tolled until the employer or
utilization review organization receives the necessary information or until the
timeframe set forth in the preceding sentence expires, whichever occurs
first.
(b) Denials by a utilization
review organization for inadequate information may be appealed pursuant to Rule
0800-02-06-.07,
at which time the authorized treating physician shall submit all information
deemed to be necessary by the Bureau. If the Bureau finds that the employer's
or utilization review organization's request did not contain the necessary
information, then the employer or utilization review organization may be
subject to sanctions and/or civil penalties as set forth in Rule
0800-02-06-.10,
at the discretion of the Administrator. In addition, if an authorized treating
physician fails to cooperate and timely furnish all necessary information,
records and documentation to an employer or utilization review organization,
then the authorized treating physician may be subject to sanctions and/or civil
penalties as set forth in Rule
0800-02-06-.10,
at the discretion of the Administrator.
(8) Employer's obligations upon receipt of
utilization review determination:
(a) Within
three (3) business days of receiving a utilization review determination that
denies the recommended treatment, the employer as defined in Rule
0800-02-06.02(8) shall give written notification to the employee and authorized
treating physician as to whether the employer will authorize any of the
recommended treatments that were denied by the utilization review organization
and what, if any, conditions shall apply to such authorization.
(b) If requested by the Bureau, within three
(3) business days of receiving a utilization review determination that is
either an approval or denial, the employer as defined in Rule
0800-02-06-.01 shall
forward such determination to the Bureau. The employer shall also forward the
notification described in subsection (6)(a) above, if applicable.
(9)
(a) The utilization review decision to deny a
recommended treatment shall remain effective for a period of 6 months from the
date of the decision without further action by the employer as defined in Rule
0800-02-06-.01(8)
if the request is for the same treatment, unless there is a material change
documented by the treating physician that supports a new review or other
pertinent information that was not used by the utilization review organization
in making the initial decision. This provision also applies to medication
denials, or modifications.
(b) A
determination by the Bureau of a utilization review appeal, whether to uphold,
overturn, or modify, shall be effective for six (6) months unless significant
new material medical information, as determined by the Administrator or
Administrator's Designee, is presented to require a new utilization review
determination by the utilization review organization or the Bureau on
appeal.
Notes
Authority: T.C.A. ยงยง 50-6-102, 50-6-118, 50-6-124, 50-6-126, and 50-6-233 and Public Chapters 282 & 289 (2013).
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