Tenn. Comp. R. & Regs. 0800-02-14-.04 - CLAIMS REPORTING REQUIREMENTS

(1) All forms required by these rules must be filed with the Bureau via EDI, unless an electronic form equivalent is specifically allowed or required by the Bureau. Requirements for EDI reporting are posted on the Bureau's website.

(2) The adjuster, when required, shall include the following information on every form it submits to the Bureau:

(a) The employee's name.

(b) The employee's date of birth.

(c) The month, day, and year of the employee's injury or illness, in the following order: mm-dd-yy or mm-dd-yyyy.

(d) The employee's social security number (SSN) as assigned by the Social Security Administration.

1. If the employee does not have a SSN, the adjusting entity shall assign an identification number that begins with the number "9" and is followed by the employee's date of birth, in the following format 9MMDDYYYY and report that information in the Employee ID Assigned by Jurisdiction EDI field.

2. If the adjusting entity later learns the correct SSN, the adjusting entity shall immediately notify the Bureau via EDI by filing the FROI 02.

(3) The adjusting entity shall ensure that all documents filed with the Bureau pursuant to this chapter, either by EDI or electronic form equivalent, are complete and legible.

(a) If a filing is not complete and error free, the filing shall be rejected. The adjusting entity shall make the correction and resubmit the filing to the Bureau. The filing will be considered "accepted" and in compliance with this section only when a complete and error free filing is received and not rejected by the Bureau.

(b) An adjusting entity will be subject to a penalty for any calendar month in which it fails to successfully transmit its documents with at least an 85% acceptance by the Bureau success rate for its filings. The assessment of this penalty will not preclude the assessment of additional penalties outlined in Rule 0800-02-13.

(4) Every adjusting entity shall submit Tennessee's First Report of Work Injury form to the Bureau as soon as possible in all cases where the reported injury results in the need for medical treatment, restricted work, the inability to work, or death, but no later than the time frames listed below.

(a) Reports of all injuries causing seven (7) calendar days of disability or fewer shall be submitted on or before the fifteenth (15th) day of the month following the month in which the injury occurred.

(b) Injuries that result in death or a personal injury of a nature that the injured employee did not return to the employee's employment within seven (7) calendar days after the occurrence of the injury must be reported no later than fourteen (14) calendar days after the report by an employer of the occurrence of the injury.

(c) Minor injuries such as scratches, scrapes, paper cuts and/or other injuries treated solely by minor first aid are not required to be reported to the Bureau. More serious injuries such as sprains, strains or bruising must be reported.

(5) Within two (2) business days of receiving a verbal or written notice of any injury from an employer, the adjusting entity shall send a Notice of a Reported Injury and a copy of the Beginner's Guide to Tennessee Workers' Compensation on the forms prescribed by the Administrator to each employee's last known address via first class U.S. Mail.

(6) Decisions on compensability shall be made by the adjusting entity within fifteen (15) calendar days of the verbal or written notice of injury. If after conducting a reasonable investigation as required by these rules a claim is denied, the adjusting entity must notify the Bureau within five (5) business days of reaching that decision by filing the required information via EDI and must provide the employee or their representative, the treating physician and the insured a non-EDI version of the Notice of Denial, available on the Bureau's website, simultaneously with the notification to the Bureau. The notice must include the basis for the denial.

(7) Adjusting entities must file the required information via EDI within five (5) business days of the initial payment of benefits and within five (5) business days of a change or termination of the payment of compensation benefits. The adjusting entity must also provide the employee or their representative and the insured a non-EDI version of the Notice of Change or Termination of Compensation Benefits simultaneously with the notification to the Bureau and must provide the explanation of the rationale upon which the modification was based.

(8) An adjusting entity electing to terminate benefits after they have been paid in a claim shall submit a MTC SROI 04 - Denial for a full denial of all further indemnity and medical benefits or a SROI MTC PD - Partial Denial for denial of a specific indemnity or medical benefit via EDI within fifteen (15) calendar days of the due date of the first omitted payment.

Notes

Tenn. Comp. R. & Regs. 0800-02-14-.04

Original rule filed December 15, 1997; effective February 28, 1998. Amendments filed May 4, 2018; effective August 2, 2018. Amendments filed April 29, 2021; effective July 28, 2021. Amendments filed July 1, 2022; effective 9/29/2022.

Authority: T.C.A. §§ 50-6-205, 50-6-233, 50-6-415, and 50-6-419.