Process

FOR RESOLVING DISPUTES BETWEEN EMPLOYERS AND PROVIDERS REGARDING BILLS. Disputes (1) Unresolved disputes between an employer and provider concerning bills due to conflicting interpretation of these Rules and/or the Medical Fee Schedule Rules and/or the Inpatient Hospital Fee Schedule Rules may be submitted within one (1) year of the date of service (DOS) to the Medical Payment Committee (the Committee) for injuries on or after July 1, 2014, in accordance with the provisions in T.C.A. § 50-6-125. A request for Committee Review shall be submitted on the current form posted by the Bureau to: Medical Director of the Bureau of Workers’ Compensation, Tennessee Department of Labor and Workforce Development, Suite 1-B, 220 French Landing Drive, Nashville, Tennessee 37243, or any subsequent address as prescribed by the Bureau. (2) Valid requests for Committee Review shall be accompanied by the form prescribed by the Bureau, shall be legible and complete, and shall contain copies of the following: (a) A copy of the results of the required reconsideration from the payor; (b) A summary of your attempts to resolve the dispute; (c) A summary of the remaining disputed issue(s); (d) Copies of the original and resubmitted bills in dispute which include dates of service, procedure codes, bills for services rendered and any payment received, and an explanation of unusual services or circumstances; (e) Copies of all explanations of benefit (EOB)/explanation of review (EOR); (f) Supporting documentation and correspondence, if any; (g) Specific information regarding the contacts made with the payor; RULES FOR MEDICAL PAYMENTS CHAPTER 0800-02-17 (h) All pertinent medical records verified by the provider including operative notes, anesthesia records, implant invoices and implant logs; (i) A redacted copy of the above information removing all patient specific protected health information in accord with 45 CFR Parts 160 and 164 as amended. For the purposes of the Medical Payment Committee, the protected health information shall include state file number, claim number, date of injury, employer name and address. (3) The party requesting Committee Review shall send a copy of the request and all documentation accompanying the request to the opposing party at the same time it is submitted to the Medical Director. (4) If the request for review does not contain proper documentation, then the Committee will decline to review the dispute. Likewise, if the timeframe in this rule is not met, then the Committee will decline to review the dispute, but such failure shall not provide an independent basis for denying payment or recovery of payment. (5) Resubmission of a request will be entertained by the Bureau and the Medical Payment Committee for 90 calendar days from the date the Committee declined to hear the original dispute but only if pertinent or new information is forwarded with the resubmission.