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Do You Know the Rule? Tenn. Utilization Review

11 May, 2023 Frank Ferreri

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Nashville, TN (WorkersCompensation.com) -- Recently, Tennessee updated its rules on utilization review, which is the evaluation of medical care services that are recommended by an authorized treating physician and provided to an injured employee. The point of a utilization review is to make sure that services are necessary, appropriate, and likely to be effective.

The following chart breaks down what's new in UR in the Volunteer State.

TopicsTennessee Rules
Basic UR processIf an authorized treating physician’s recommended treatment cannot be approved by an adjuster, the adjuster may seek an opinion from another physician through a utilization review organization.
The decision reached by the URO agent only addresses medical necessity, but not causation or compensability. When recommended treatment is not certified, they are reported back to the injured worker and the physician. Either can appeal the denial. Denials must be based on the Official Disability Guidelines, which are independent, evidence-based guidelines for treating common work injuries. 
Treatments that must be sent to URThe following treatments are required to be sent to UR:
(1) In-patient hospital admissions
(2) Non-emergency ground and air ambulance services
(3) When the adjuster cannot approve the treatment
When can recommended treatment be denied?Recommended treatment can be denied only by a Utilization Review Physician who is of the same or similar specialty and licensed in the State of Tennessee. Denials must be accompanied by a utilization review report that gives the reasons for denial and the name and credentials of the utilization review physician.  
AppealsThese are the steps involved in an appeal for denied treatment:
(1) Receive Denial Letter & C-35A. If the URO denies a physician’s recommended treatment, the URO or the employer’s insurance adjuster is required to provide the injured worker and the treating physician with the denial letter and a pre-filled Form C-35A that can be sent either to the insurer for reconsideration or to the Bureau of Workers’ Compensation.
--> The injured worker, their attorney, or treating physician has 30 calendar days from receipt of the denial letter to appeal the utilization review decision to the Bureau of Workers' Compensation.
(2) If appealed to the Bureau and the necessary medical records are received, the Bureau's Medical Director will make a determination to approve, modify, or deny the treatment. This decision is final for administrative purposes.
(3) The fee charged by the Bureau is paid by the insurer.
Deadlines(1) Adjusters have four business days after being notified by the provider of the recommended treatment to approve the treatment or send the recommend treatment to approve the treatment or send the recommendation to its URO.
(2) The URO has seven business days to make a decision on the recommended treatment and notify all parties of the decision.
--> If the URO does not possess all necessary information in order to render the utilization review determination, the agent may request additional information, in writing, from the authorized treating physician.
--> The authorized treating physician shall send the request within five business days of receipt of the written request.
--> The number of business days is extended until the URO receives the necessary information or until the five business days timeframe expires, whichever occurs first.
MediationParties who are not satisfied with an appeal may file for mediation. Reviewing the denial, understanding its reasoning and gathering information might result in agreement. If mediation is not successful, a judge may rule on whether the ATP’s recommended treatment was appropriate.
Rules violationsAn employer, insurer, third party administrator, or URO who is found to have violated the UR rules may be subjected to a penalty of not less than $50 nor more than $5,000 per violation. The Bureau may also institute a temporary or permanent suspension of the right to perform utilization review services for workers’ compensation claims, if the utilization review agent has established a pattern of violations.

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    About The Author

    • Frank Ferreri

      Frank Ferreri, M.A., J.D. covers workers' compensation legal issues. He has published books, articles, and other material on multiple areas of employment, insurance, and disability law. Frank received his master's degree from the University of South Florida and juris doctor from the University of Florida Levin College of Law.

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