Claims Reporting Requirements

(1) All forms required by these rules must be filed with the Bureau via EDI, unless an electronic form equivalent is specifically allowed or required by the Bureau. Requirements for EDI reporting are posted on the Bureau’s website. (2) The adjuster, when required, shall include the following information on every form it submits to the Bureau: (a) The Employee’s name. (b) The Employee’s date of birth. (c) The month, day, and year of the Employee’s injury or illness, in the following format: mm-dd-yyyy. (d) For the initiating First Report of Injury (FROI), the Employee’s social security number (SSN) as assigned by the Social Security Administration. 1. If the Employee does not have a valid SSN, the adjusting entity shall contact the Bureau via email to wc.edi@tn.gov to request an “Assigned by Jurisdiction Number” in order to file the initiating FROI. 2. If the adjusting entity later learns the correct SSN, the adjusting entity shall immediately notify the Bureau via EDI by filing the FROI 02. (3) The Employee Security ID shall be required on all filings submitted after an initial FROI has been accepted. (4) The adjusting entity shall ensure that all documents filed with the Bureau pursuant to this chapter, either by EDI or electronic form equivalent, are complete and legible. CLAIMS HANDLING STANDARDS CHAPTER 0800-02-14 (a) If a filing is not complete and error free, the filing shall be rejected. The adjusting entity shall immediately make the identified correction(s) and resubmit the filing to the Bureau. The filing will be considered “accepted” and in compliance with this section only when a complete and error free filing is received and not rejected by the Bureau. (b) An adjusting entity may be subject to a penalty for any rejected EDI filing that is not immediately corrected, resubmitted and accepted by the Bureau. (c) An adjusting entity will be subject to a penalty for any calendar month in which it fails to successfully transmit its documents with at least an 85% acceptance by the Bureau success rate for its filings. The assessment of this penalty will not preclude the assessment of additional penalties outlined in Rule 0800-02-13. (5) Every adjusting entity shall submit Tennessee’s First Report of Work Injury form via EDI to the Bureau as soon as possible in all cases where the reported injury results in the need for medical treatment, restricted work, the inability to work, or death, but no later than the time frames listed in T.C.A. § 50-3-702. (6) Within two (2) business days of receiving a verbal or written notice of any injury from an Employer, the adjusting entity shall send a Notice of a Reported Injury and a copy of the Beginner’s Guide to Tennessee Workers’ Compensation on the forms prescribed by the Administrator to each Employee’s last known address via first class U.S. Mail. (7) Adjusting entities shall follow the EDI requirements as posted on and/or linked from the Bureau’s website and in effect at the date of the filing. (8) Initial decisions on compensability shall be made by the adjusting entity within fifteen (15) calendar days of the verbal or written notice of injury. (a) In claims when compensability is questioned, adjusters shall contact all authorized medical providers, or their staff members, who have rendered medical services to an Employee within three (3) business days of an initial office visit to investigate details concerning the injury and treatment and make a preliminary compensability determination. (b) Initial decisions regarding compensability can be changed as new or additional information is obtained by the adjusting entity. When compensability decisions are changed, all appropriate forms must be filed timely. If after conducting a reasonable investigation as required by these rules a claim is denied, the adjusting entity shall notify the Bureau within five (5) business days of reaching that decision by filing the required information via EDI and must provide the Employee or their representative, all authorized medical providers and the insured a non-EDI version of the Notice of Denial, available on the Bureau’s website, simultaneously with the notification to the Bureau. The notice shall include the basis for the denial. The adjusting entity is responsible for paying for all services rendered by each authorized medical provider not previously denied by the adjusting entity until the Bureau’s receipt of the notice of denial. (c) An adjusting entity electing to deny a claim, in whole or in part, and terminate any or all future benefits after benefits have been paid in a claim shall submit an MTC SROI 04- Denial for a full denial of all further indemnity and medical benefits or an SROI MTC PD-Partial Denial for a denial of a specific indemnity or medical benefit via EDI within fifteen (15) calendar days of the due date of the first omitted payment. (9) Adjusting entities shall file the required information via EDI within five (5) business days of the initial payment of benefits and within five (5) business days of a change or termination of the CLAIMS HANDLING STANDARDS CHAPTER 0800-02-14 payment of compensation benefits. The adjusting entity shall also provide the Employee or their representative and the insured a non-EDI version of the Notice of Change or Termination of Compensation Benefits simultaneously with the notification to the Bureau and shall provide the explanation of the rationale upon which the modification was based. (10) For open claims, adjusting entities must submit MTC QT quarterly updates regarding the status of the claim until the case is closed, at which time it must submit a Final Report MTC FN. (a) The initial MTC QT must be received no earlier than fourteen (14) calendar days prior to the end of the three (3) months from the date of the injury with subsequent filings due each three (3) months thereafter until the case is closed. (b) If a Final Report MTC FN has been filed and the claim is being reopened to pay ongoing disability benefits, an MTC QT is due no later than the next three-month interval based on the date of the injury. (c) The quarterly filing is not required when the First Report of Injury is for Notification Only (Claim Type N) or FROI 04 (with no PY, IP, EP, or AP on file) or SROI SX with DN0418-Suspension Reason Code-Full-S8 (Jurisdiction Change) has been accepted. (d) If any indemnity or medical payments are made after a Claim Type N or FROI 04 has been accepted, the claim will re-open, the appropriate MTC will be required and an MTC QT will be due at the appropriate time.