Tenn. Comp. R. & Regs. 0800-02-25-.02 - DEFINITIONS
(1) "Act" means the applicable Workers'
Compensation Law in effect.
(2)
"Administrator" means the chief administrative officer of the Tennessee Bureau
of Workers' Compensation, or the Administrator's designee.
(3) "Authorized Treating Physician" means the
practitioner chosen from the panel required by T.C.A. §
50-6-204,
or a practitioner who has received a referral from the original authorized
treating physician if the employer has not provided an alternative referral
within three business days. "Authorized Treating Physician" also means any
practitioner specifically authorized by the employer.
(4) "Bureau" means the Tennessee Bureau of
Workers' Compensation attached for administrative purposes to the Tennessee
Department of Labor and Workforce Development.
(5) "Employee" means an employee as defined
in T.C.A. §
50-6-102, but
also includes the employee's representative or legal counsel.
(6) "Employer" means an employer as defined
in T.C.A. §
50-6-102, but
also includes an employer's insurer, third party administrator, self-insured
employers, self-insured pools and trusts, as well as the employer's
representative or legal counsel, as applicable.
(7) "Health care provider" includes, but is
not limited to, the following: licensed individual chiropractic physician,
dentist, physical therapist, physician, physician assistant, optometric
physician, podiatrist, surgeon, occupational therapist, group of practitioners,
hospital, free standing surgical outpatient facility, health maintenance
organization, industrial or other clinic, occupational healthcare center, home
health agency, visiting nursing association, laboratory, medical supply
company, community mental health center, pharmacist/pharmacy, and any other
facility or entity providing treatment or health care services for a
work-related injury.
(8) "Medical
Director" means the Medical Director of the Tennessee Bureau of Workers'
Compensation appointed by the Administrator pursuant to T.C.A. §
50-6-126, or the
Medical Director's designee.
(9)
"Medically necessary" or "medical necessity" means healthcare services,
including medications, that a physician (or other healthcare provider acting
within their scope of practice), exercising prudent clinical judgment, would
provide to a patient for the purpose of preventing, evaluating, diagnosing or
treating an illness, injury, disease or its symptoms, and that are:
(a) In accordance with generally accepted
standards of medical practice; and
(b) Clinically appropriate, in terms of type,
frequency, extent, site and duration; and considered effective for the
patient's illness, injury or disease. Treatment primarily for the convenience
of the patient, physician, or other healthcare provider does not constitute
medical necessity.
(10)
"Treatment guideline" means the Institute of Medicine (2011) definition of a
"clinical practice guideline": "statements that include recommendations
intended to optimize patient care that are informed by a systematic review of
the evidence and an assessment of the benefit and harms of alternative care
options."
(11) "Utilization review"
means evaluation of the necessity, appropriateness, efficiency and quality of
medical care services, including the prescribing of one (1) or more Schedule
II, III, or IV controlled substances for pain management for a period of time
exceeding ninety (90) days from the initial prescription of such controlled
substances, provided to an injured or disabled employee based on medically
accepted standards and an objective evaluation of those services provided;
provided, that "utilization review" does not include the establishment of
approved payment levels, a review of medical charges or fees, or an initial
evaluation of an injured or disabled employee by a physician specializing in
pain management;
(a) "Utilization review" does
not include elective requests for clarification of coverage, referrals,
consultations, second opinions from medical providers, or office
visits.
(b) "Utilization review"
does not include analysis of or opinions regarding medical causation or
compensability.
Notes
Authority: T.C.A. §§ 50-6-102, 50-6-122, 50-6-124, 50-6-126, 50-6-233, 56-6-703, and 56-61-102.
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