Definitions

The following definitions are for the purpose of these Utilization Review Rules, Chapter 0800-02-06: (1) “Administrator” means the chief administrative officer of the Bureau of Workers’ Compensation of the Tennessee Department of Labor and Workforce Development, or the Administrator’s designee. (2) “Authorized treating physician” means the practitioner chosen from the panel required by T.C.A. § 50-6-204 or a practitioner referred to by the practitioner chosen from the panel required by T.C.A. § 50-6-204, as appropriate. Authorized treating physician shall also include any other medical professional recognized and authorized by the employer or designated by the Bureau to treat any injured employee for a work-related injury or condition. (3) “Bureau” means the Tennessee Bureau of Workers’ Compensation. (4) “Business day” means any day upon which the Tennessee Bureau of Workers’ Compensation is open for business. (5) “Claims adjuster” or “adjuster” means a representative of an adjusting entity who investigates workers’ compensation claims for the purposes of making compensability determinations, files or causes claims forms to be filed with the Bureau, commences benefits, and/or makes settlement recommendations based on the insured’s liability on behalf of a self-insured employer, trade, or professional association, third party administrator, and/or insurance company or carrier. (6) “Compliance Contact” means the email address for the unit or individual, other than the claim’s adjuster, responsible for responding to matters regarding the claim on behalf of the employer’s insurer, self-insured employer, third party administrator, or self-insured pool and trust. (7) “Contractor” means an independent utilization review organization not owned by or affiliated with any carrier authorized to write workers’ compensation insurance in the state of Tennessee with which the Administrator has contracted to provide utilization review, including peer review, for the Bureau, as referred to in T.C.A. § 50-6-124. GENERAL RULES OF THE WORKERS’ COMPENSATION PROGRAM CHAPTER 0800-02-06 UTILIZATION REVIEW (8) “Employee” means an employee as defined in T.C.A. § 50-6-102, but also includes the employee’s legally authorized representative or legal counsel. (9) “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 legally authorized representative or legal counsel, as applicable. (10) “Health care provider” includes, but is not limited to, the following: licensed individual, chiropractor, dentist, occupational therapist, physical therapist, physician, doctor of osteopathy, surgeon, optometrist, podiatrist, pharmacist, 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, and any other facility or entity providing treatment or health care services for a work-related injury within the scope of their license. (11) “Inpatient services” means services rendered to a person who is formally admitted to a hospital and whose length of stay is in accordance with the Medicare rules for “inpatient status.” (12) “Medical Director” means the Medical Director of the Bureau appointed by the Administrator pursuant to T.C.A. § 50-6-126, or the Medical Director’s designee chosen by the Administrator to act on behalf of the Medical Director. (13) “Medically necessary” or “medical necessity” means healthcare services that a physician, 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, including Treatment Guidelines as defined in Rule 0800-02-06-.01(19); (b) Clinically appropriate, in terms of type, frequency, extent, site and duration; and considered effective for the patient's illness, injury or disease; (c) Not primarily for the convenience of the patient, physician, or other healthcare provider; and (d) Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury or disease. (14) “Outpatient services” means a service provided by the following, but not limited to, types of facilities: physicians’ offices and clinics, hospital emergency rooms, hospital outpatient facilities, community mental health centers, outpatient psychiatric hospitals, outpatient psychiatric units, and freestanding surgical outpatient facilities also known as ambulatory surgical centers. Outpatient services may also include hospital admissions that do not qualify as “inpatient admissions” under Medicare regulations appropriate for the date of discharge. (15) “Parties” means the employee, authorized treating physician, employer, and their legal representatives as those terms are defined herein. (16) “Peer-to-Peer” means the communication between the authorized treating physician and the utilization review physician regarding the utilization review of treatment recommended by the GENERAL RULES OF THE WORKERS’ COMPENSATION PROGRAM CHAPTER 0800-02-06 UTILIZATION REVIEW authorized treating physician. “Peer” as used in these rules may include the authorized treating physician and the utilization review physician. (17) “Practitioner” means a person currently licensed in good standing to practice as a doctor of medicine, doctor of osteopathy, doctor of chiropractic, or doctor of dental medicine or dental surgery. (18) “Preauthorization” for workers’ compensation claims means that the employer, prospectively or concurrently, authorizes the payment of medical benefits. Preauthorization for workers’ compensation claims does not mean that the employer accepts the claim or has made a final determination on the compensability of the claim. Preauthorization for workers’ compensation claims shall not mean utilization review as defined in these rules. (19) “Recommended treatment” means the recommendation of the authorized treating physician to perform or refer treatments, procedures, surgeries, including medications but not limited to Schedule II, III, or IV controlled substances after 90 days, and/or admissions in either an inpatient or outpatient setting. Recommended treatment shall also mean emergency treatments, procedures, surgeries, and/or admissions when retrospective review is performed. (20) “Reconsideration” means a request from the authorized treating physician to the utilization review organization or the employer to review the initial denial of treatment recommended by the authorized treating physician. (21) “Records” means medical records and reports regarding an employee’s claim for workers’ compensation benefits. Records include electronic imaging of such documents. (22) “Same or similar specialty” means a medical doctor, doctor of osteopathy, chiropractor or dentist (M.D., D.O., D.C., D.D.S. or D.M.D.) trained in the same or similar specialty of medicine that typically manages the medical condition, procedure, or treatment under discussion and thus is able to understand the rationale and current medical evidence for the request. The determination of same or similar specialty shall be made by the Administrator. (23) “Treatment Guidelines” means 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. The statements and other documents that accompany the guidelines are those that are adopted by the Bureau effective on January 1, 2016, and periodically updated as new information warrants. (24) “Utilization review” means evaluation of the necessity, appropriateness, efficiency and quality of medical 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 upon medically accepted standards and an objective evaluation of the medical care 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. “Utilization review,” also known as “Utilization management,” does not include the evaluation or determination of causation or the compensability of a claim. For workers’ compensation claims, “utilization review” does not include preauthorization as defined in these rules. The employer shall be responsible for all costs associated with utilization review and shall in no event obligate the employee, health care provider or Bureau to pay for such services. (25) “Utilization review agent/organization” (URO) means an individual or entity authorized to do business and provide utilization review services in Tennessee. All utilization review GENERAL RULES OF THE WORKERS’ COMPENSATION PROGRAM CHAPTER 0800-02-06 UTILIZATION REVIEW agents/organizations are required to be certified by the Commissioner of Commerce and Insurance pursuant to T.C.A. §§ 56-6-701, et seq., and registered with the Bureau, complying with the accreditation requirement in T.C.A. § 50-6-124(a). (26) “Utilization review physician” means an actively Tennessee-licensed doctor of medicine, doctor of osteopathy, doctor of chiropractic, or doctor of dental medicine or dental surgery, who is board certified, who is in good standing, who is in the same or similar specialty as the recommending authorized treating physician, and who makes utilization review determinations for the utilization review organization.