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).
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.