Tenn. Comp. R. & Regs. 0800-02-27-.10 - REQUIRED TRAINING PROGRAM FOR CERTIFIED ADJUSTING ENTITIES
(1) Prior to being recognized as a certified
adjusting entity by the Bureau, an adjusting entity shall establish and
implement a training program for adjusters that process Tennessee claims and
shall provide:
(a) Newly-hired medical-only
adjusters with at least eight (8) hours of claims-related training;
(b) Newly-hired or newly-appointed claims
adjusters with at least twelve (12) hours of claims-related training;
(c) Medical-only and claims adjusters, who
are not newly-hired or newly-appointed, with at least two (2) hours of
Tennessee-specific training each year; and
(d) Supervising Adjusters who are not
newly-hired or newly-appointed with at least four (4) hours of
Tennessee-specific claims processing training each year.
(2) All required training for new hires or
newly-appointed adjusters shall be provided within the first thirty (30)
calendar days of the date or hire or appointment to the position and shall
include:
(a) Overview of the information
contained on the Tennessee Bureau of Workers' Compensation's Internet
homepage
(b) Overview of the
Tennessee Workers' Compensation Law including:
1. Notice requirements for employers and
claimants
2. Adjuster duties when
an injury is reported by an employer
3. Time frame for accepting/denying
claim
4. Elements of good
faith
5. Claims forms filing
requirements/EDI
6. Exclusive
remedy
(c) Insurance
principles of compensation
1. Medical
evidence
2.
Investigations
3.
Documentation
4. Tennessee-specific
Compensability Issues
(i) Course of
employment/Arising out of employment
(ii) Covered injuries
(iii) Occupational diseases
5. Denying a claim
(i) Willful misconduct
(ii) Intoxication
(iii) Failure to use safety
equipment
(iv) Statute of
limitations
6.
Fraud
(d) Medical billing
codes
(e) Benefits provisions
1. Tennessee requirements for medical
panels
2. Medical
benefits
3. Temporary disability
benefits
4. Permanent disability
benefits and issues concerning impairment ratings
5. Future medical benefits
6. Death benefits
(f) Return to work and vocational
rehab
(g) Cumulative trauma and
gradually occurring injuries
(h)
Medical terminology and abbreviations
1.
Medical reports
2. Medical
specialties
3. Common occupational
injuries and diseases
4. Common
medical tests
(i)
Controlling Costs
1. Employee Choice of
Physician Form C-42
2. Medical Fee
Schedule
3. Case
Management
4. Utilization
Review
5. Treatment Guidelines and
Drug Formulary
(j)
Settlement negotiations
1. Mediation and
Ombudsman Services of Tennessee (MOST)
2. Court of Workers' Compensation
Claims
3. Workers' Compensation
Appeals Board
(k) Ethical
Issue
1. Elements of bad faith
2. Tennessee's Penalty
statutes
(3)
All required training for medical-only and claims adjusters and Supervisors,
who are not newly-hired or newly-appointed, shall include information regarding
industry best practices as well as any updates to the Workers' Compensation Law
or to the Bureau's rules and/or programming areas.
(4) Adjusting entities recognized by this
program shall be allowed to indicate its claims processing services are
"Recognized by the Tennessee Bureau of Workers' Compensation as a certified
adjusting entity in advertising and on its letterhead only during the time
frame the adjusting entity is so recognized.
(5) The Bureau may, at its discretion,
provide the names and other non-protected personal information, of any adjuster
or adjusting entity that has been certified by this program on its website or
in any other means it chooses.
Notes
Authority: T.C.A. ยงยง 50-6-101, 50-6-119, 50-6-127, 50-6-233, 50-6-415, and 50-6-419.
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