Peer-To-Peer Communications

This section provides for peer-to-peer communications. It applies to all treatment requests that have been denied or modified through utilization review. (1) All denials or modifications of requests for treatment shall be made by a utilization review organization in accordance with this Rule 0800-02-06. (2) Except as modified in this section, this applies to all recommended treatments (therapies, medications, diagnostic studies, procedures, referrals, consultations, and second opinions) GENERAL RULES OF THE WORKERS’ COMPENSATION PROGRAM CHAPTER 0800-02-06 UTILIZATION REVIEW for which approval by an employer (as defined in T.C.A. 50-6-102 and Rule 0800-02-17-.03) is necessary under Rule 0800-02-06. (3) If, through utilization review, the employer or the utilization review organization on behalf of the employer, denies or modifies a request for recommended treatment, the authorized treating physician may request reconsideration of the denial to include a peer-to-peer conference with a utilization review physician designated by the utilization review organization. The timeframe for the peer-to-peer conference shall be within ten (10) days of the receipt of the request for a peer-to-peer conference being received by the adjuster or the utilization review organization. The denial notification sent by the utilization review organization shall provide the necessary information for the authorized treating physician to establish a request for the peer-to-peer conference. The request for the peer-to-peer conference shall be made by electronic communication to the contact listed on the denial notification. If the utilization review organization offers both electronic communication and telephonic communication, the authorized treating physician must specify which reconsideration option they choose in their electronic communication to the utilization review organization contact listed on the denial notification. The telephonic conference may be an interactive audio/video conference by mutual consent. If the authorized treating physician chooses telephonic communication, the authorized treating physician shall provide the following information in the electronic communication to the utilization review organization: (a) The telephone number for the utilization review physician to call and the name of the authorization treating physician or designee, if any; (b) The date for the conference not less than two (2) business days nor more than seven (7) business days from the date of receipt of the request by the utilization review organization; and (c) Three (3) two (2)-hour periods on the date specified in accordance with (b) above during which the requesting medical provider or authorized treating physician (or designee) will be available to participate in the conference between the hours of 8:00 A.M. and 5:00 P.M. (Central Time), Monday through Friday, holidays excluded. (4) The designated utilization review physician (who may not be the physician who performed the review) shall have reviewed and have available all of the medical information and records used in making the initial determination including any further information requested by the authorized treating physician, utilization review organization and/or utilization review physician before the call. (5) As an alternative to the telephone or interactive audio/video conference, the utilization review organization may utilize an interactive web/email portal application for the peer-to-peer conference under the same time frames as (3). This alternative conference shall be initiated within two (2) business days of the authorized treating physician’s request for this method of communication and shall provide for two (2) or more explanations if appropriate or necessary from the authorized treating physician and two (2) or more responses from a utilization review physician if appropriate or necessary to the authorized treating physician. (6) Failure of the reviewing physician designated by the utilization review organization to participate in the peer-to-peer telephonic conference during the date and time specified or in the electronic communication option, unless a second good faith effort by the utilization review organization has occurred, shall result in the approval of the requested non-invasive treatment, medication, diagnostic study, referral, second opinion or consult unless good cause exists for the failure to participate. In the event of good cause for failure to participate in the peer-to-peer conference, the reviewing physician shall contact the requesting medical provider to reschedule the peer-to-peer conference. The rescheduled peer-to-peer GENERAL RULES OF THE WORKERS’ COMPENSATION PROGRAM CHAPTER 0800-02-06 UTILIZATION REVIEW conference shall be held no later than two (2) business days following the original conference date. This provision does not include invasive procedures for patient safety. A request for reconsideration as defined in these rules or the option of appeal to the Office of Tennessee Bureau of Workers’ Compensation Medical Director should be utilized when failure to complete the peer-to-peer communication for invasive procedures occurs. If the reviewing physician is unavailable for any reason in the timeframe scheduled, an alternate reviewing physician with access to the file may participate in the call. (7) Failure of the requesting authorized treating physician (or designee) to participate in the peer- to-peer conference during the time he/she specified availability or in the electronic communication option, if requested, may result in the denial of the requested treatment, referral, consult, or second opinion, unless good cause exists for the failure to participate. In the event of good cause for failure to participate in the peer-to-peer conference, the requesting provider shall contact the reviewing physician to reschedule the peer-to-peer conference. The rescheduled peer-to-peer conference shall be held no later than two (2) business days following the original conference date. (8) A verifiable, complete, and accurate electronic record of all peer-to-peer telephonic contacts and interactive electronic communications, if any, shall be saved by the utilization review organization for a period of two (2) years from the date of receipt of the reconsideration request and shall be made available to the Bureau upon request. The authorized treating physician or their designee shall note in the medical records the outcome of all peer-to-peer communications. Once in the medical records, the communication becomes a permanent record. Such information shall be available to the Bureau upon request.