Tenn. Comp. R. & Regs. 0800-02-06-.07 - APPEALS OF UTILIZATION REVIEW DECISIONS
(1) Every denial
of a recommended treatment shall be accompanied by a form prescribed by the
Bureau that informs the employee as defined in these rules and authorized
treating physician how to request an appeal with the Bureau. The employee or
authorized treating physician shall have thirty (30) calendar days from receipt
of the initial denial or the denial on reconsideration by an employer as
defined in these rules to request an appeal with the Bureau. The form and
accompanying instructions provided shall be the current form and instructions
adopted by the Bureau and posted on the Bureau's website. The Medical Director
may extend the time to appeal for good cause.
(2) Upon receipt of an appeal request by an
employee or authorized treating physician :
(a)
The Bureau or its designated contractor shall conduct the utilization review
appeal. The Bureau or its designated contractor may contact the authorized
treating physician for the purpose of obtaining any necessary missing
information. The Bureau or its designated contractor shall determine the
medical necessity of the recommended treatment as soon as practicable after
receipt of all necessary information. The Bureau or its designated contractor
shall then transmit such determination to the authorized treating physician ,
employee, and employer. The determination of the Bureau or its designated
contractor is final for administrative purposes, subject to the provisions of
subsections (3)-(5) of this Rule.
(b) If any information necessary for the
determination of the appeal is not within the possession of the Bureau , then
any party not providing such information when requested by the Bureau may be
subject to sanctions and/or civil penalties as set forth in Rule
0800-02-06-.10, at the discretion of the Administrator .
(c) The Bureau shall charge fees, as posted
on its website, pursuant to Public Chapter 289 (2013) and T.C.A. §
50-6-204(j) for each utilization review appeal that it completes. The fee shall
be paid by the employer within thirty (30) calendar days of the Bureau 's
completion of the appeal. Failure to comply with this requirement may result in
a civil penalty of not less than $50 nor greater than $5000 per violation. If
there is a pattern of violations, the Administrator may consider suspension of
participation in the Bureau's utilization review program. If the fee and/or
penalty remain unpaid for a further 30 days, the Administrator may impose
further civil penalties or sanctions, or request that the Department of
Commerce and Insurance apply penalties/sanctions in accordance with their
policies. The appeal of any fee or civil penalty assessed pursuant to this
section shall be made in accordance with the Uniform Administrative Procedures
Act, T.C.A. §§
4-5-101, et seq., and the most current procedural
rules of Chapter 0800-02-13, as may be amended periodically in the future,
which are incorporated as if set forth fully herein.
(3) If the determination of the Bureau is an
approval of part or all of the recommended treatment, then the Medical Director
shall issue a determination that specifies the treatment(s) that is/are
medically necessary. The penalty provisions of T.C.A. §§
50-6-238 and
50-6-118 shall apply to these determinations issued pursuant to this subsection
(3).
(4) For dates of injury on or
after July 1, 2014, if the determination of the Medical Director is to approve
part or all of the recommended treatment, then within seven (7) calendar days
of the receipt of the determination letter from the Medical Director ,
referenced in subsection (3) above, the insurance carrier is required to inform
the provider that the procedure and/or treatment, including medications, has
been approved and request that the procedure or treatment be scheduled. The
penalties for noncompliance with this subsection are those set forth in T.C.A
§
50-6-118.
(5) A
determination of denial is effective for a period of 6 months from the date of
the determination as set forth in Rule 0800-02-06-.06(7).
(6) For dates of injury on or after July 1,
2014, notwithstanding the provisions of subsection (4), if any party, including
an employee , employer, or a carrier, disagrees with a determination of the
Medical Director's recommended or denied treatment, then the aggrieved party
shall file a Petition for Benefit Determination (PBD) with the Court Of
Workers' Compensation Claims within fifteen (15) calendar days of the receipt
of the determination to request a hearing of the dispute in accordance with
applicable statutory provisions. To avoid a penalty for noncompliance with the
Medical Director's order, an employer who files a Petition for Benefit
Determination (PBD) shall also request a stay of enforcement from the Court of
Workers' Compensation Claims pending the outcome of the Petition for Benefit
Determination (PBD).
(7) For dates
of injury prior to July 1, 2014, if the determination of the Medical Director
is to approve part or all of the recommended treatment, and an order for
medical benefits is issued by the Bureau , within fifteen (15) calendar days of
the receipt of the order the insurance carrier is required to inform the
provider that the procedure and/or treatment, including medications, has been
approved and request that the procedure or treatment be scheduled. The
penalties for noncompliance with this subsection are those set forth in T.C.A
§
50-6-238 [Applicable to injuries occurring prior to July 1, 2014]. The
determination of the Medical Director is final for administrative purposes. If
the employer disagrees with the determination, the employer may file a Request
for Mediation (RFM) with the Bureau or civil action with a court of proper
jurisdiction and shall request a stay of enforcement from the Bureau penalty
program pending the outcome of the Request for Mediation (RFM) or civil action
in a court of proper jurisdiction.
(8) Notwithstanding any other provision to
the contrary, if the parties agree on a recommended treatment after the
employer 's utilization review organization has denied such, then the parties
may, by joint agreement, override the determination of the employer 's
utilization review organization or the Bureau and approve the recommended
treatment. Such approval by agreement shall terminate any appeal to the Bureau
and no fee shall be required of the employer for any such appeal that has yet
to be determined by the Bureau .
Notes
Authority: T.C.A. §§ 50-6-102, 50-6-118, 50-6-124, 50-6-126, 50-6-204, 50-6-233, and 50-6-238 and Public Chapters 282 & 289 (2013).
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