RULES OF THE DEPARTMENT OF LABOR DIVISION

OF WORKERS’ COMPENSATION

CHAPTER 0800-2-14

CLAIMS HANDLING STANDARDS

TABLE OF CONTENTS

0800-2-14-.01 – Purpose and Scope

0800-2-14-.02 – Definitions

0800-2-14-.03 – Reporting Requirements

0800-2-14-.04 – Investigation

0800-2-14-.05 – Payment of Benefits

0800-2-14-.06 – Resolution Process

0800-2-14-.07 – Medical Cost

0800-2-14-.08 – Enforcement

0800-2-14-.09 – Fraud

0800-2-14-.01  – PURPOSE AND SCOPE.

(1) Purpose: To assure that employees sustaining an injury arising out of and in the scope of employment are treated fairly and to assure that workers’ compensation claims are handled in an appropriate and uniform manner.

(2) Scope: The provisions of this chapter shall apply to all employers in the State of Tennessee subject to provisions of the Workers’ Compensation Law.

Authority: TCA §50-6-419. Administrative History: Original rule filed on December 15, 1997; effective February 28, 1998.

0800-2-14.02 – DEFINITIONS.

(1) “Act” means the applicable Workers’ Compensation Law in effect.

(2) “Insurer” or claims handler means self-insured employer, trade or professional association, third party administrator and/or insurance company.

(3) “Insured” or employer means any individual, firm, association or corporation, or the receiver, or trustee of the same, or the legal representative of a deceased employer, using the services of not less than five (5) persons for pay, except as provided in TCA §50-6-113 dealing with subcontractors and those engaged in the construction industry, and in the case of an employer engaged in the mining and production of coal, one (a) employee for pay. If the employer is insured, it shall include the employer’s insurer, unless otherwise herein provided.

(4) “Employee” includes every person, including a minor, whether lawfully or unlawfully employed, the president, any vice-president, secretary, treasurer or other executive officer of a corporate employer without regard to the nature of the duties of such corporate officials, in the service of an employer, as employer is defined in (3) above, under any contract of hire or apprenticeship, written or implied. Any reference herein to an employee who has been injured shall, where the employee is dead, also include such employee’s legal representatives, dependents and other persons to whom compensation may be payable under the Workers’ Compensation Law; “Employee” also includes a sole proprietor or a partner, who devotes full time to the proprietorship or partnership and elects to be included in the definition of employee by filing written notice thereof with the Division of Workers’ Compensation at least thirty (30) days before the occurrence of any injury or death, and may at any time withdraw the acceptance by giving notice of the withdrawal to the division.

(5) “Claimant” means an employee who alleges an injury or occupational disease sustained in the course and scope of employment.

(6) “Director” means the Director of the Division of Workers’ Compensation or the appointed agent of such Director.

(7) “Division” means the Workers’ Compensation Division of the Tennessee Department of Labor.

(8) “Injury” means an injury by accident arising out of and in the course of employment which causes either disablement or death of the employee and shall include occupational diseases arising out of and in the course of employment which cause either disablement or death of the employee.

Authority: TCA §§50-6-102 and 50-6-113. Administrative History: Original rule filed on December 15, 1997; effective February 28, 1998.

0800-2-14-.03 – REPORTING REQUIREMENTS.

(1) In order to ensure that Workers’ Compensation claims are acted on promptly, employers shall report verbally or in writing all known or reported accidents to their insurer within one working day of knowledge of injury.

(2) Every insurer shall file with the Division a report of accident on Form C-20 (Tennessee Employer’s First Report of Work Injury) pursuant to Rule 0800-2-1-.06. Effective January 1, 1998, Form C-20 shall require the signature of the injured employee. If the injured employee is unable to sign the form or refuses to sign the form, an explanation shall be required.

(3) A wage statement to insure the correct rate of compensation shall be filed with the Division and shall accompany the Form C-22 (Notice of First Payment of Compensation) or Form C-23 (Notice of Denial of Benefits). Filings shall be made pursuant to Rule 0800-2-1-.07.

Authority: TCA §50-6-419 and 50-3-702. Administrative History: Original rule filed on December 15, 1997; effective February 28, 1998.

0800-2-14-.04 – INVESTIGATION.

(1) Upon verbal or written notice of any injury from an employer, the insurer shall make verbal or written contact with the claimant within two (2) working days to confirm facts of the claim, history of prior claims, work history, wages, and job duties. This may include a recorded statement.

(2) Insurers shall make personal or telephone contact with the employer within two (2) working days of notice of accident to verify accident details. Insurers and employers shall obtain a description of the job and prior claim information of the claimant within five (5) working days. All pertinent witnesses shall be contacted by the insurer as they become known.

(3) Insurers shall verify the average weekly wage of the claimant consistent with the Division’s requirements and the requirements of TCA §50-6-205.

(4) Insurers shall contact physicians who have rendered medical services to a claimant within seventy-two (72) hours of verbal or written notice to confirm injury and treatment and make preliminary compensatory determination.

(5) All aspects of contacting and attempts to contact insureds, the claimant and physicians shall be documented within the insurer’s file.

(6) When third party subrogation recovery is appropriate, insurers shall develop a strategy to promptly obtain needed evidence.

(7) Decisions on workers’ compensation insurance coverage and compensability shall be made within fifteen (15) days of verbal or written notice of accident. All pertinent documents of the Division of Workers’ Compensation shall be filed within fifteen (15) days of verbal or written notice of accident. Claimants and employers shall be notified of the decision of compensability within fifteen (15) days of verbal or written notice of accident.

(8) Denial of a claim shall be supported with documented results of the investigation. Form C-23 (Notice of Denial) shall be filed with the Division within ten (10) days of denial and a copy of Form C-23 shall be provided to the claimant within the same time frame.

(9) If an insurer denies a claim, the insurer shall provide documentation which meets the statutory criteria for denial on Form C-23 upon request by the Division, employer, claimant, and/or their legal representatives.

Authority: TCA §§50-6-205 and 50-6-419. Administrative History: Original rule filed on December 15, 1997; effective February 28, 1998.

0800-2-14-.05 – PAYMENTS OF BENEFITS.

(1) Compensation payments for an injury shall be received by the claimant no later than fifteen (15) days after notice of injury.

(2) All workers’ compensation benefits shall be issued timely to assure the injured employee receives the benefits on or before the date they are due.

Authority: TCA §50-6-419. Administrative History: Original rule filed on December 15, 1997; effective February 28, 1998.

0800-2-14-.06 – RESOLUTION PROCESS.

(1) A medical impairment rating and date of maximum medical improvement by the treating physician, and information needed to settle a claim shall be documented in writing.

(2) Insurers shall make an offer of settlement in writing within thirty (30) days of receipt of information specified above, Rule 0800-2-14-.06(a). The claimant shall sign the offer of settlement indicating approval or rejection of the offer.

(3) An agreed settlement shall be finalized by order of a court or approval by the Division as required by TCA §50-6-206. A copy of the court order or division approval shall be filed with the Commissioner of Tennessee Department of Labor.

(4) If settlement is not agreed upon, a Benefit Review Conference may be requested pursuant to TCA §50-6-237.

Authority: TCA §§50-6-237, and 50-6-419. Administrative History: Original rule filed on December 15, 1997; effective February 28, 1998.

0800-2-14.07 – MEDICAL COSTS.

(1) All medical costs owed under the Tennessee Workers’ Compensation Law shall be paid within forty-five (45) days of receipt of bill or invoice. Also within forty-five (45) days, if additional documentation is required for payment, the party requesting payment shall be informed of the needed information. There is no obligation to make payment until adequate documentation is received.

(2) Medical invoices shall contain the following characteristics:

(a) CPT (Procedure) Code

(b) ICD 9 (Diagnostic) Code

(3) Remuneration inquiries shall be made directly to the insurer.

Authority: TCA §50-6-419. Administrative History: Original rule filed on December 15, 1997; effective February 28, 1998.

0800-2-14-.08 – ENFORCEMENT.

(1) In addition to other penalties provided by applicable law and regulation, violations of any of the above rules shall be subject to enforcement by Commissioner of the Tennessee Department of Labor pursuant to TCA §50-6-419(c).

Authority: TCA §50-6-419. Administrative History: Original rule filed on December 15, 1997; effective February 28, 1998.

0800-2-14-.09  – FRAUD.

All provisions regarding the detecting, prosecuting, and/or preventing of workers’ compensation fraud shall be governed by TCA §50-6-127 and Title 56, Chapter 47.

Authority: TCA §50-6-419. Administrative History: Original rule filed on December 15, 1997; effective February 28, 1998.

 

A complete set of the Rules of Tennessee Department of Labor Division of Workers’ Compensation regarding claims handling standards in its original content can be found at http://www.tn.gov/sos/rules/0800/0800-02/0800-02-14.pdf