Tenn. Comp. R. & Regs. 0800-02-17-.21 - PROCESS FOR RESOLVING DISPUTES BETWEEN EMPLOYERS AND PROVIDERS REGARDING BILLS

Disputes

(1) Unresolved disputes between an employer and provider concerning bills due to conflicting interpretation of these Rules and/or the Medical Fee Schedule Rules and/or the Inpatient Hospital Fee Schedule Rules may be submitted to the Medical Payment Committee (the Committee) on or after July 1, 2014, in accordance with the provisions in T.C.A. § 50-6-125. A request for Committee Review may be submitted on the form posted by the Bureau within one (1) year of the date of service to: Medical Director of the Bureau of Workers' Compensation, Tennessee Department of Labor and Workforce Development, Suite 1-B, 220 French Landing Drive, Nashville, Tennessee 37243, or any subsequent address as prescribed by the Bureau.

(2) Valid requests for Committee Review shall be accompanied by the form prescribed by the Bureau, shall be legible and complete, and shall contain copies of the following:

(a) Copies of the original and resubmitted bills in dispute which include dates of service, procedure codes, bills for services rendered and any payment received, and an explanation of unusual services or circumstances;

(b) Copies of all explanations of benefit (EOBs);

(c) Supporting documentation and correspondence, if any;

(d) Specific information regarding the contacts made with the employer;

(e) A verified or declared written medical report signed by the provider and all pertinent medical records; and

(f) A redacted copy of the above information removing all patient specific identifying information.

(3) The party requesting Committee Review shall send a copy of the request and all documentation accompanying the request to the opposing party at the same time it is submitted to the Medical Director.

(4) If the request for review does not contain proper documentation, then the Committee will decline to review the dispute. Likewise, if the timeframe in this rule is not met, then the Committee will decline to review the dispute, but such failure shall not provide an independent basis for denying payment or recovery of payment.

(5) Resubmission of a request will be entertained by the Bureau and the Medical Payment Committee for 90 calendar days from the date the Committee declined to hear the original dispute but only if pertinent or new information is forwarded with the resubmission.

Notes

Tenn. Comp. R. & Regs. 0800-02-17-.21

Public necessity rule filed June 5, 2005; effective through November 27, 2005. Public necessity rule filed November 16, 2005; effective through April 30, 2006. Original rule filed February 3, 2006; effective April 19, 2006. Amendments filed June 12, 2009; effective August 26, 2009. Amendments filed March 12, 2012; to have been effective June 10, 2012. The Government Operations Committee filed a stay on May 7, 2012; new effective date August 9, 2012. Amendment filed December 26, 2013; effective March 26, 2014. Repeal and new rules filed November 27, 2017; effective February 25, 2018. Administrative changes made to this chapter on September 10, 2019; "Tennessee Workers' Compensation Act" or "Act" references were changed to "Tennessee Workers' Compensation Law" or "Law." Amendments filed June 27, 2023; effective 9/25/2023.

Authority: T.C.A. §§ 50-6-126, 50-6-204, 50-6-205, 50-6-226, and 50-6-233 (Repl. 2005) and Public Chapters 282 & 289 (2013).