Tenn. Comp. R. & Regs. 0800-02-06-.01 - 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.
(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 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 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.
Notes
Authority: T.C.A. §§ 50-6-102, 50-6-124, 50-6-126, and 50-6-233 and Public Chapters 282 & 289 (2013).
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