Public Chapter 289 (2013) and Tennessee Code Annotated § 50-6-204 (j)(5)authorize an employer to use utilization review to determine the medical necessity of a treatment recommended by an authorized treating physician, and, in instances required by the workers’ compensation statutes or the medical fee schedule.
Utilization review is required in the form of pre-admission review for all inpatient hospital admissions, and concurrent review should be done after discharge. Emergency admissions require utilization review within one business day of the admission. Utilization review is required on chiropractic, physical and occupational services after twelve visits. In order to facilitate expedited utilization review, whenever a physician orders physical therapy or occupational therapy the physician should include the diagnosis on the prescription for physical therapy or occupational therapy. Utilization review is required for psychological treatment services in excess of fifteen (15) visits.
Pursuant to Tennessee Code Annotated § 50-6-204(j)(5) and Rule 0800-02-06-.07 (2) (c), the Division is authorized to impose a fee for the administration of the utilization review appeal process. Accordingly, the Workers’ Compensation Division, or their contractor, Eckman/Freeman & Associates, will collect a fee not to exceed $250 for each review conducted. After the utilization review appeal is completed, an invoice will be submitted to the employer, or their workers’ compensation insurance carrier, for payment. The fee shall be paid by the employer, or their workers’ compensation insurance carrier, within thirty (30) calendar days of the completion of the utilization review appeal. If the fee is not paid within the time frame, then a 10% interest payment shall accrue for every thirty (30) calendar days that the fee remains unpaid.
The Workers’ Compensation Division, or their contractor, Eckman/Freeman & Associates, will provide notice to the employer’s workers’ compensation insurance carrier’s adjuster whenever it receives an appeal of a utilization review decision rendered pursuant to the statute. If the carrier decides to rescind the original utilization review decision, the carrier must inform the Workers’ Compensation Division, or their contractor, Eckman/Freeman & Associates, of its decision within two (2) business days of the date the Division, or their contractor, notified the carrier of the utilization review appeal to avoid assessment of the fee. In order to avoid the fee, information that the utilization review decision has been rescinded must be provided to the entity– meaning either the Division or Eckman-Freeman–that sent the carrier notice of the utilization review appeal.
The Notice of Appeal Rights for a Utilization Review Denial (Form-C35A) was updated in December of 2010. Please note that any older versions of the Form-C35A will not be accepted and will be returned to the carrier and/or their utilization review company as invalid. The carrier and/or their utilization review company will be required to resubmit the correct version of the form.
This information was generated by the Tennessee Department of Labor and the original source can be found here http://www.tn.gov/labor-wfd/wcomp/forms/UR%20Appeal%20Fee%20Notice.pdf