General Requirements

(1) Any Employer or adjusting entity that knowingly, willfully and intentionally causes a claim to be paid under any health or sickness and accident insurance or that fails to provide reasonable and necessary medical treatment, including a failure to reimburse when the Employer or adjusting entity knew that the claim arose out of a compensable work-related injury shall be assessed a civil penalty of $500.00. The Employer or adjusting entity shall not offset any benefit paid by that insurance against its temporary total disability benefit liability. Each adjusting entity shall designate at least one (1) contact person to serve as a liaison between the entity and the Bureau. The designee must have the ability to provide information about claims assignments, status of payments and contact information for the adjusting entity’s adjusters as well as the entity’s primary EDI contact. The designee’s name, title, direct phone number, email address, and mailing address shall be provided to the Bureau, on a form prescribed by the Bureau, in January of each year and within fifteen (15) calendar days of any change regarding the designee for that entity. Each January and July, the designee shall provide the Bureau, on a form prescribed by the Bureau, with the name(s), direct phone number(s), email address(es), and mailing address(es) for each individual adjuster that is performing duties covered by these Rules. Each separate act of not timely notifying the Bureau of a change in the designee or not timely providing the information, required in this subsection regarding adjusters shall constitute a separate violation and may subject the entity to assessment of a civil penalty, per Rule 0800-02-01-.10, for each separate act. (2) Each adjusting entity shall designate at least one (1) contact person to serve as a liaison between the entity, medical providers, injured workers or their representatives and the Bureau. The designee shall have the ability to provide information and resolution of disputes about billing/bill review, preferred provider networks, associated discounts and the status of payments concerning medical benefits afforded under the Act with an appropriate response within fifteen (15) calendar days from the date of the initial request for information or reconsideration. The designee’s name, title, direct phone number, email address, and mailing address shall be provided to the Bureau, on a form prescribed by the Bureau, in January and July of each year and within fifteen (15) calendar days of any change regarding the designee for that entity. Each separate act of not timely notifying the Bureau of a change in the designee or not timely providing the information required in this subsection shall constitute a separate violation and may subject the entity to assessment of a civil penalty, per Rule 0800- 02-01, for each separate act. (3) Each hospital or hospital system and clearing house shall, when requested by the Bureau, designate at least one (1) contact person to serve as a liaison between the entity, medical providers, and the Bureau. The designee shall have the ability to provide information and resolution of disputes about billing/bill review, preferred provider networks, associated discounts and the status of payments concerning medical benefits afforded under the Act. The designee’s name, title, direct phone number, email address, and mailing address shall be provided to the Bureau, on a form prescribed by the Bureau, in January and July of each year and within fifteen (15) calendar days of any change regarding the designee for that entity. (4) Upon the written request of the Bureau’s Medical Director, a medical provider shall designate at least one (1) contact person, within fifteen (15) calendar days of the request, to provide complete information about medical coding and the submission and reimbursement of CLAIMS HANDLING STANDARDS CHAPTER 0800-02-14 medical bills, records requests and forms completion. The designee’s name, title, direct phone number, email address, and mailing address shall be provided to the Bureau. (5) If an adjusting entity contracts with a trading partner to electronically file transactions with the Bureau on the entity’s behalf, or uses a trading partner’s software product for electronically sending transactions to the Bureau, a Trading Partner Agreement form, provided by the Bureau, must be fully completed and submitted to the Bureau via email to wc.edi@tn.gov annually, by July 1st of each year and within fifteen (15) calendar days of any change. If an adjusting entity does not contract with a trading partner to electronically file transactions, the adjusting entity must complete and submit the Trading Partner Agreement form in the same manner and frequency as stated above. The adjusting entity shall remain responsible for the timely filing of transactions required by this Rule, processing of acknowledgements, and any penalties and fines that may result from untimely electronic filings. (6) All adjusting entities or trading partners shall utilize anti-virus software to remove any viruses on all electronic transmissions prior to sending electronic transmissions to the Bureau. The adjusting entity or trading partner shall maintain the anti-virus software with the most recent anti-virus update files from the software provider. If the adjusting entity or trading partner sends a transmission that contains a virus which prevents the Bureau from processing the transmission, the transmission will not be considered as having been received.