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Workers' Compensation Division - Insurance Adjusters Information

THE RESPONSIBILITIES OF AN ADJUSTER

Tennessee has strict claims handling standards for adjusters and employers to ensure that work-related injuries and illnesses are reported timely and correctly.  Employers covered by the Tennessee Workers’ Compensation Act must submit all known or reported injuries or illnesses to their insurance carriers, unless they are qualified to be a self-insured employer, within one (1) working day of the employer’s knowledge of the injury or illness.  Insurance carriers or self-insured employers must file notice of the injury or illness with the Division through Electronic Data Interchange (EDI) on Tennessee Employer’s First Report of Work Injury or Illness (Form C-20) as soon as possible, but not later than fourteen (14) days after knowledge of the injury or illness.  Additional information on filing may be found on the Electronic Data Interchange (EDI) page.  Reportable workplace injuries or illnesses are those that cause:

  • An employee to receive medical treatment outside of the employer’s premises;
  • Their death; or,
  • Their absence from work, or their retention of a permanent impairment. 

WHEN AN INJURY IS REPORTED, THE ADJUSTER MUST:

  • Make a personal or telephone contact with the employer and the injured employee within two (2) working days of its notice of injury to confirm the facts of the claim, the history of any prior claims, and the injured employee’s work history, wages, and job duties. Insurance carriers and employers must obtain a description of the job and prior claim information of the claimant within five (5) working days.  This may include a recorded statement. 
  • After obtaining a Medical Waiver and Consent Form (Form C-31) from the employer that is signed by the injured employee, contact physicians who have rendered medical services to a claimant within seventy-two (72) hours to confirm details concerning the injury and treatment and to make a preliminary compensability determination.  All aspects of contacting and attempts to contact employers, injured workers and/or medical providers must be documented and kept within the adjuster’s files.
  • Contact all pertinent witnesses as they become known.
  • Accept or deny the claim within fifteen (15) days of its knowledge of the injury and file the appropriate form(s) as indicated below.  The insurance carrier must notify the employer and the injured employee of its decision within those fifteen (15) days.

COMPENSABILITY DETERMINATION
Decisions on workers’ compensation insurance coverage and compensability must be made within fifteen (15) days of a verbal or written notice of an accident or injury.  Upon making its determination after a proper investigation the employer, self-insured employer, or adjuster must file, with the Division, the appropriate forms.  Claimants and employers must be notified of the decision of compensability within fifteen (15) days of the notice. 

PAYMENT OF BENEFITS
Compensation payments for a compensable work-related injury or illness must be received by the injured employee no later than fifteen (15) calendar days after the notice of injury.  Unpaid or untimely paid benefits may be subject to a penalty.

SETTLEMENT PROCESS
Parties are encouraged to negotiate the final settlement of claims.  A medical impairment rating, a date of maximum medical improvement determined by the treating physician and all other information needed to settle a claim shall be documented in writing in claims involving permanent impairments.  Adjusters shall make an offer of settlement in writing within thirty (30) calendar days of receipt of information specified above.  An agreed settlement shall be finalized by either an order of the court or by approval by a Workers’ Compensation Specialist within the Division.  A copy of the court order or division’s approval shall be filed with the Division.  If settlement is not agreed upon in private negotiations, a Benefit Review Conference may be requested.  Parties are precluded from filing a lawsuit to resolve the matter until the Benefit Review process has been exhausted.

For additional information about this topic, please call 615-532-4812 or 1-800-332-2667.

IMPORTANT NOTES: 

  • All workers’ compensation benefits shall be issued timely to assure the injured employees receive the benefits on or before the date they are due.

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CLAIMS FILING THROUGH ELECTRONIC DATA INTERCHANGE (EDI)

Electronic Data Interchange (EDI) affords insurers and the Division of Workers' Compensation a method of exchanging certain workers’ compensation claims information electronically and thereby avoiding multiple entries of data into computer systems.  EDI is fast, accurate, reliable and cost effective.  Insurers sign a trading partner agreement with the Division.  This agreement includes testing the reporting system to determine if the transmission mechanism is acceptable. Upon completion of testing, the Division will notify the trading partner of approval to submit production data. The International Association of Industrial Accident Boards and Commissions (IAIABC) offers education on reporting workers' compensation data electronically.  Below is a listing of the forms of the Division that are required to be submitted electronically.

I-1

Certificate of Insurer

 

I-2

Notice of Cancellation, Reinstatement or Endorsement

 



C-20

First Report of Work Injury

FROI MTC 00

C-21

Monthly Report of Non-compensable Injuries

FROI MTC 00 must be filed for each claim that was required to be reported on the C21.

C-22

Notice of First Payment

SROI MTC IP = First Payment
SROI MTC RB = Reinstatement

C-23

Notice of Denial

FROI MTC 04 = Denial, no payments have been made
SROI MTC 04 = Denial, payments have been made
Note:  Denials may be filed via EDI but MUST be filed on form C23 as well.

 

 

 

C-26

Notice of Change/Termination of Benefits

SROI MTC CA = Change Benefits
SROI MTC S1/S9 = Termination of Benefit

C-29

 Final Report of Payment

Notice of Final Payment SROI MTC FN


Crosswalk TN WC to FROI SROI
The Crosswalk TN WC to FROI SROI will give the TN WC Form that is equivalent to EDI Release 1 fields and vice versa.  Click Here

TN FROI Element Requirement Table
The TN FROI Element Requirement Table lists all FROI Release 1 fields and whether the field is Mandatory, Optional or Conditional.  Click Here

TN SROI Element Requirement Table
The TN SROI Element Requirement Table lists all SROI Release 1 fields and whether the field is Mandatory, Optional or Conditional.  Click Here

Annual Report Requirements
The Annual Report Requirements document lists the requirements and the process for generating the report.  Click Here

TN EDI Release 1 Implementation Guide
The TN EDI Release 1 Implementation Guide contains the processes of the TN EDI Release 1 Implementation and has a large amount of information concerning the process.  Click Here

EDI Error Message Meanings
The EDI Error Message Meanings contains descriptions of the error codes that are received in the Acknowledgement File that is returned when an EDI Claims file has been received by the Division of Workers’ Compensation.  Click Here

For additional information about this topic, please call Emily Shacklett at (615) 532-1313 or Cathy Dodd at (615)253-2050.

IMPORTANT NOTES: 

  • The Forms I-1 & Form I-2 are required to be electronically filed with the Division by the employers’ insurance carrier when coverage is obtained from a licensed Workers’ Compensation Carrier authorized to write workers’ compensation policies in the State of Tennessee within 30 days from procurement or renewal of suitable workers’ compensation insurance or within 30 days of an employer’s acceptance as a Self-Insured or participation in a Pool, Trust or a fund authorized to act as a Self-Insured Employer that has been approved by the Department of Commerce & Insurance, Self-Insured Section.
  • Any errors submitted on the filings of Form I-1 or Form I-2 must be corrected by the insurance carrier that submitted the information.  
  • If an EDI filing is not correct when it is submitted, it will be rejected by the Division.  An error message will provide the carrier the reason for the rejection.  EDI files that are rejected by the Division due to an error by the carrier are not considered to have been actually filed and may put the carrier at risk for penalty if the error is not corrected timely.  Click here to see some of the most common error messages and for instructions on how to correct those errors.
  • Proof of Coverage (POC) Information must be submitted electronically to a vender that is IAIABC-certified and approved by the Division. The National Council on Compensation Insurance (NCCI) is IAIABC certified and authorized to submit POC data on each insurance carrier’s behalf.
  • The Final Report of Payment and Compensation Form C29 must be filed on all claims that do not result in permanency (settlement). All cases that result in permanency will require the filing of the SD-1. The SD-1 is a paper form and must be filed with the court or with the Division at the time of settlement.
  • The Notice of Denial of Claim for Compensation Form C-23 must be filed with the Division on paper and may be filed electronically, also.

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TENNESSEE’S MEDICAL FEE SCHEDULE

All medical costs owed under the Tennessee Workers’ Compensation Law must be paid according to the Rules of Tennessee Workers’ Compensation Medical Fee Schedule (MFS).  The schedule applies to all medical services and medical equipment or supplies and is applicable to all injured employees, no matter where the injury took place, so long as that person is claiming workers’ compensation benefits under Tennessee’s workers’ compensation law.  Fees are based on the date the medical service is received, not on the date of the employee’s injury. 

The Medical Fee Schedule is made-up of three (3) parts, called chapters, of administrative rules and has undergone several revisions since the first version became effective on July 1, 2005. 

  • The first chapter, Chapter 0800-2-17, is called the Medical Cost Containment Program Rules.  This part contains general information applicable to the other two chapters, including most of the definitions used throughout all three chapters, as well as the purpose, scope, general guidelines and procedures.  This chapter also explains the basis for the Medical Fee Schedule (Medicare for most of the Medical Fee Schedule), the time-period payers have to timely reimburse providers for undisputed bills, what happens if payers do not comply, and appeal procedures. 
  • The second chapter, Chapter 0800-2-18, is the actual Medical Fee Schedule Rules and addresses the proper conversion factors to use for calculating the maximum allowable amounts for physicians’ professional services (determined by the classification of the CPT codes), the maximum allowable amounts that may be paid for certain types of medical devices and equipment (such as durable medical equipment and prosthetics and orthotics), the maximum allowable amounts for ambulatory surgical centers (ASC’s) and hospital outpatient services, penalties for violations of the Medical Fee Schedule, and what actually constitutes a violation.
  • The third chapter, Chapter 0800-2-19, is the In-patient Hospital Fee Schedule that sets out how hospitals should be reimbursed for in-patient admissions.  Unlike most of the Medical Fee Schedule, this chapter, for the most part, is not based on Medicare methods, but reimburses hospitals on a per-day or “per diem” basis.  This chapter also contains definitions and procedures specifically applicable to inpatient hospital reimbursements.

Most definitions needed for proper use of the Tennessee Medical Fee Schedule are provided in the Medical Cost Containment Program Rules, specifically Rule 0800-2-17-.03. These should be consulted thoroughly to familiarize you with the particular meanings of terms used throughout the Medical Fee Schedule and in the Inpatient Hospital Fee Schedule.

MEDICAL COSTS
All medical costs owed under the Tennessee Workers’ Compensation Law must be paid according to the Rules of the Medical Fee Schedule, Chapters 0800-02-17, 0800-02-18 and 0800-02-19.  The adjuster must file the following reports with the Division when applicable:

  1. Attending Physician’s Report (Form C-30).
  2. Final Medical Report (Form C-30A) although a party, in lieu of a deposition, may utilize the Standard Form Medical Report For Industrial Injuries (Form C-32).
  3. Final Report of Payment and Receipt of Compensation (Form C-29) must be submitted in all cases that are not settled, are not tried in court and do not result in permanent disability payments through Electronic Data Interchange (EDI) within thirty (30) days following the final payment of compensation.  Form C-29 shall include all compensation benefits paid on a claim, including all medical expenses, hospital expenses, funeral expenses, and legal costs.

For additional information about this topic, please call 615-532-4812 or 1-800-332-2667.

IMPORTANT NOTES: 

  • Unlike fee schedules in some other states, Tennessee’s Medical Fee Schedule does not set an absolute fee for services.  Instead, it sets a maximum amount that may be paid.  Providers and payers are encouraged to negotiate amounts below the maximum set in the Medical Fee Schedule, but shall not pay an amount above the Fee Schedule maximum amount.
  • Reimbursement to all providers shall be the lesser of: (1) the provider’s usual charge, (2) the maximum fee schedule under these Rules, or (3) the MCO/PPO or any other negotiated and contracted amount.  This lesser of comparison must be done on the total bill or amount due, NOT on a line-by-line comparison of items. 
  • A payer paying in excess of the Fee Schedules and a provider retaining excessive reimbursement over 90 days is a violation of the Fee Schedule Rules and may result in penalties up to a $10,000.00 civil penalty against both payer and provider, among other measures, based on the Commissioner’s (or the Commissioner’s Designee’s) discretion. See Rule 0800-2-18-.02(2)(b)(4.) 
  • When there is no specific methodology in these Rules for reimbursement, the maximum reimbursement is 100% of Medicare. Whenever there is not Medicare methodology, maximum reimbursement is Usual & Customary or U & C (80% of billed charges). See Rule 0800-2-18-.02(a). 
  • Procedure codes for unlisted procedures should only be used when there is no procedure code which accurately describes the services rendered. These codes require a written report and are paid at a maximum allowable amount of usual and customary (80% of billed charges.) See Rule 0800-2-17-.06. 
  • Unless otherwise stated in the Fee Schedule Rules, the current effective Medicare procedures and guidelines are to be used. See Rule 0800-2-18-.02(a). 
  • Relative Value Units (“RVUs”) may be obtained from the current edition of the Medicare RBRVS: The Physician’s Guide. This should be used in conjunction with the current edition of the AMA’s CPT Coding Guide. These books may be obtained by contacting the American Medical Association at American Medical Association, 515 N. State Street Chicago, IL 60610, telephone (800) 621-8335, or by visiting the AMA’s bookstore online at the American Medical Association’s website: www.ama-assn.org

When extraordinary services resulting from severe head injuries, major burns, severe neurological injuries, or any injury requiring an extended period of intensive care, a greater fee may be allowed up to 150% of the professional service fees normally allowed under these Rules. This provision does not apply to In-patient Hospital facility fees. See Rule 0800-2-1. 

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OMBUDSMAN

The Workers’ Compensation Ombudsman Program provides assistance to employees, employers or any other party in a workers’ compensation claim that is not represented by legal counsel. Any party that is not represented by legal counsel may request the services of a workers’ compensation Ombudsman by contacting the Division at its toll-free phone number—1-800-332-2667.

For more information about the Division’s Ombudsman Program, click here.

An Ombudsman shall have authority including, but not limited to:

  • Meeting with and providing information to parties not represented by legal counsel;
  • Communicating with all parties and providers in the claim;
  • Assisting the parties in the completion of forms;
  • Facilitating the exchange of medical records; and
  • Investigating and attempting to resolve disputes without resorting to the Division’s Alternative Dispute Resolution Process and/or the Court of Workers’ Compensation.

While an Ombudsman cannot provide legal advice, an Ombudsman can:

  • Provide information on workers’ compensation laws and the Division’s policies, practices, procedures, and rules;
  • Inform participants of their rights and obligations under the law; and
  • Assist participants in completing forms, obtaining medical records and scheduling appointments.

IMPORTANT NOTES: 

  • An Ombudsman cannot be called to testify in any proceeding and no statement or representation made to an Ombudsman shall be considered by a Workers’ Compensation Judge for any purpose.
  • If a person or entity receiving the services of an Ombudsman obtains legal counsel in the case or dispute for which the services of an Ombudsman were sought, the person or entity shall immediately notify the Division of the representation and shall discontinue use of the services provided by an Ombudsman.

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THE SD-1 STATISTICAL DATA FORM

The department has developed a Statistical Data Form (Form SD-1) for collecting data relevant to assessing the workers' compensation system.  The form must be filed with the Division or the clerk of the court in which the settlement order is filed for every workers' compensation matter that is concluded by settlement, whether approved by a court or the department. 

  • A settlement approved by the department shall not become final until the statistical data form required by this section is fully completed and received by the department.
  • In cases involving a workers' compensation settlement that is approved by a court, the completed form shall be filed at the same time as the order approving the settlement is filed and shall be filed with the clerk of the court in which the settlement order is filed. 
  • In cases involving a workers' compensation case that is resolved by trial, the completed form shall be filed at the same time as the final order is submitted to the trial court for approval and shall be filed with the clerk of the court in which the matter was tried. 

IMPORTANT NOTES: 

  • A settlement in a workers' compensation matter is not final until the SD-1 form required by this section is fully completed and filed. 
  • A form is not required to be filed in cases that involve reconsideration of a prior settlement or trial judgment order for which a form was filed at the time of submission of the prior order.
  • A form is not required to be filed if the only issue resolved by an order is the closing of future medical benefits that remained open pursuant to a prior order for which a form was filed at the time of submission of the prior order.
  • It is the responsibility of the employer or the employer's agent to complete and file the SD-1 form, contemporaneously with the filing of the final order or settlement. The employee and any agent of the employee are required to cooperate with the employer in completing this form. 

For additional information about this topic, please call 615-532-4812 or 1-800-332-2667.

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THE PENALTY PROGRAM

The Penalty Program investigates and assesses penalties for violations of the Tennessee Workers’ Compensation Act other than those covered by the Uninsured Employers Fund (UEF) and the Employee Misclassification Education and Enforcement Fund (EMEEF).   The Program enforces several penalties, including:

    • A 25% penalty for failure to pay or to timely pay temporary disability benefits; (If assessed, this penalty goes to the injured employee not to the Division.)    
    • A $10,000+ penalty for failure to timely comply with a Specialist’s or Administrator’s Designee’s order; and
    • A penalty for an insurance company’s or self-insured employer’s failure to timely file claims forms; (Timely claims forms are important to the Division as the forms supply important claims information to the legislature for its consideration regarding changes to the Workers’ Compensation Act.)
    • Other various penalties.

Click here for a summary of workers’ compensation penalties.

For additional information about this topic, please call 615-532-4812 or 1-800-332-2667.

IMPORTANT NOTES: 

  • A 25% penalty for failure to pay or to failure to timely pay temporary disability benefits assessed by the department is payable to the injured employee.  All other penalties collected go into the Second Injury Fund.
  • To be considered timely and to avoid the $10,000+ penalty, employers or their insurance carriers are required to comply with the Benefit Review Program’s Attorney Specialist’s Order within fifteen (15) calendar days of its receipt, unless a request for Administrative Review is filed.
    • If Administrative Review is requested, the obligation to comply with the Order is suspended until the Administrative Review is resolved.
  • To be considered timely and to avoid the $10,000+ penalty, Employers or their insurance carriers are required to comply with the Administrative Review Program’s Administrator’s Designee’s Order within ten (10) calendar days of receipt.
  • Continued failure to comply with an Order 21 days after its receipt shall result in an additional penalty of $1,000.00 per day.
  • When determining whether or not a penalty is appropriate, there is a “strict liability” standard applied.  Either the employer or their insurance carrier timely complied with the Order, or it didn’t.

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WHO NEEDS WORKERS’ COMPENSATION--INSURANCE COVERAGE REQUIREMENTS—THE UNINSURED EMPLOYERS FUND (UEF)

The Uninsured Employers Fund (UEF) is the program that is responsible for the enforcement of the insurance coverage requirements of the Tennessee Workers’ Compensation Act.  Generally speaking, every employer in the state that has five (5) or more employees must secure workers’ compensation insurance coverage for their employees either by purchasing a policy from an insurance carrier or by qualifying as a self-insured employer with the Department of Commerce and Insurance.  However, employers in the construction business or trades (construction service providers) that have one or more employees must secure coverage as well or be specifically exempted (see the Workers’ Compensation Exemption Registry page for more information).  Employers in the coal-mining industry must secure coverage if they have one (1) employee.

The goal of the staff of the UEF is to ensure every Tennessee employer that is required to have coverage is in compliance with the law.  Two equally important objectives are reached when they are successful. 

  • First, a worker suffering an on-the-job injury or illness will be better able to receive the benefits they are entitled to under the law. 
  • Secondly, fairness in competition is achieved.  It is not fair for responsible Tennessee employers to be in competition with non-compliant employers.  Those unfair employers undercut responsible employers by not having to bear the expense of providing workers’ compensation insurance. 

The UEF investigates and penalizes employers that are required by law to carry workers’ compensation insurance but then fail to either provide that coverage or to qualify as self-insured employers with the Tennessee Department of Commerce and Insurance.  There are two (2) monetary penalties that can be assessed against employers that are legally-required to secure coverage but fail to do so.  The penalties equal up to a total of 2 ½ times the estimated annual workers compensation insurance premium that would have been charged to that employer.  To report employers that are violating the law, please complete this Request for Investigation form or call 800-332-2667 and ask to speak to the UEF Program.

For additional information about this topic, please call 615-532-4812 or 1-800-332-2667.

IMPORTANT NOTES: 

  • Every employer subject to the Workers’ Compensation Law is required to display the Tennessee Workers' Compensation Insurance Notice (Click here for the Spanish version).  This posting notice should be posted conspicuously in the place of business for easy viewing by all employees and must contain the business’:
    • Name,
    • Telephone number,
    • Physical address of the employer representative that can be used to confirm if the employer is subject to the workers' compensation law and, if so, to obtain the name of the employer’s workers' compensation insurance carrier, and
    • The employer representative’s telephone number and physical address that should be notified in the event of an injury.   If the employer has multiple locations, a separate Posting should be posted at each location.
  • If an employer cannot find an insurance company to write a workers' compensation policy, it should contact the Tennessee Workers' Compensation Insurance Plan at (800) 471-6767 or www.twcip.com
  • Family members and corporate officers are included when determining the number of employees if they meet the definition of employee.
  • Sole Proprietors, Partners and Members of LLC’s are excluded from the count of employees that determines whether or not an employer is covered by the Tennessee Workers’ Compensation Act.  Corporate officers are afforded the right to exempt themselves from a workers’ compensation policy, but are NOT excluded from the count of employees unless they are not paid or compensated.
  • When determining whether or not a penalty is appropriate, there is a “strict liability” standard applied.  Either the employer had the required coverage (no penalty) or it didn’t (penalty assessed).
  • Effective March 1, 2011, owners of construction businesses are also required to carry workers’ compensation coverage on themselves or be listed on the Exemption Registry.   
  • The insurance carrier providing coverage to an employer must electronically-file proof of that coverage with this Division.
  • State and local governments and those employing farm laborers or domestic help are exempt from the coverage requirements, but may elect to purchase workers’ compensation coverage anyway.
  • If an employer is not required to have worker’s compensation insurance and an employee gets hurt at work, the injured worker is not entitled to workers' compensation benefits, but he/she is not barred or prohibited from filing a lawsuit against the employer.

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THE EMPLOYEE MISCLASSIFICATION EDUCATION AND ENFORCEMENT FUND (EMEEF)

The Employee Misclassification Education and Enforcement Fund (EMEEF) program is an extension of the Uninsured Employers Fund and identifies and penalizes employers that:

  • Misclassify employees as independent contractors,
  • Underreport the number of employees or amount of its total payroll,
  • Misrepresent the type of work that is being performed, and/or
  • Unlawfully deducts workers’ compensation insurance premiums from workers’ paychecks.

The Tennessee Workers’ Compensation Act gives guidance in determining whether a worker is an employee or not.  The following factors must be considered in determining whether or not a person is an employee or an independent contractor:

    • The right to control the conduct of the work,
    • The right of termination,
    • The method of payment (such as a company check),
    • The freedom to select and hire helpers,
    • Who furnishes the tools and equipment,
    • Who schedules the working hours, and
    • Whether or not the worker has the freedom to work for other entities.

Here is a table showing some of the differences between Independent Contractors and Employees:

Independent Contractors generally:

Employees generally:

  • Are free from direction and control by supervisors
  • Are under the direction of a supervisor
  • Have the necessary skills and training to complete the job prior to being hired
  • Are trained by the employer on how to perform the work
  • Have a business location and performs services for multiple customers
  • Work at the employer’s location, though possibly multiple customer worksites
  • Set their own hours and determine their own prices for contracted services
  • Have their work hours determined by a supervisor
  • Are not eligible for employee benefits
  • Accept wages, salaries, commissions, or bonuses that are determined by a supervisor
  • Provide their own equipment and tools and supply some of the materials used to complete job
  • Use tools that are owned and/or controlled by an employer
  • Are personally liable for errors and/or accidents
  • Are not personally liable for errors or accidents.  Usually, the employer is liable.
  • Have the right to hire and fire workers
  • Can be hired or fired by the employer


Most subcontractors are sole proprietors or partners.  Sole proprietors and partners are usually not covered by their workers' compensation policy when it is written; only the employees are covered.  The subcontractor that is a sole proprietor or partner may elect to be covered by his/her own workers' compensation policy by filing an Election of Sole Proprietor or Partner to Come Within the Provisions of the Tennessee Workers’ Compensation Law (Form I-4) with the Division of Workers’ Compensation.  The Form I-4 becomes effective 30 days after the Division receives the forms.  The original fully-completed and notarized form should be sent to the Division.

A subcontractor, with the agreement of the general contractor, can elect to be covered by the general contractor's workers' compensation insurance by filing an Agreement of General Contractor to Provide Workers’ Compensation Coverage to Subcontractor (Form I-15) with the Division or a subcontractor can have his own workers' compensation coverage and furnish proof of this coverage to the general contractor.   The Form I-15 allows the general contractor to withhold premiums from the subcontractor's payroll to cover the subcontractor and its employees.  The form must be signed by the general contractor and the subcontractor, notarized and filed with the Division.  Failure of the general contractor to file the form with the Department of Labor and Workforce Development does not relieve the obligation of the insurance company to provide coverage to a subcontractor when the subcontractor can produce evidence of payment of premiums to the insurance company.  The subcontractor, acting as a self-employed individual, is not an employee of the general contractor and has no coverage as long as he/she is not working as an employee.   There is no form that will waive the rights of employees of subcontractors.  The subcontractor must provide coverage for his employees either through an agreement with the general contractor or by purchasing a separate policy. 

For additional information about this topic, please call 615-532-4812 or 1-800-332-2667.

IMPORTANT NOTES: 

  • It is illegal for an employer to require an employee to pay any portion of the business’ workers’ compensation premiums.   If unlawful deductions are discovered, civil penalties are assessed by the program in an amount equal to the amount unlawfully deducted.  If other unlawful employment practices are discovered, the program takes appropriate action including referrals to other state agencies.  
  • To report employers that are violating the law, please complete this tip form or call 800-332-2667 and ask to speak to the Compliance Program.
  • A general contractor can require a subcontractor to have workers' compensation insurance and refuse to sign the Form I-15.
  • Failure of the general contractor to file the I-15 Form with the Department of Labor and Workforce Development does not relieve the obligation of the insurance company to provide coverage to a subcontractor when the subcontractor can produce evidence of payment of premiums to the insurance company. 
  • To determine whether an employer is engaged in construction, please contact the National Council on Compensation Insurance (NCCI) at 800-622-4123 to obtain a four-digit classification code.  Classification codes for all construction classifications are available at: http://www.tn.gov/insurance/documents/NCCI_ContractingIndustryGroupCodes.pdf .  

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THE WORKERS’ COMPENSATION EXEMPTION REGISTRY

The Workers’ Compensation Exemption Registry, administered by the office of the Tennessee Secretary of State, is for the purpose of providing a mechanism for legitimate business owners in the construction industry (construction service providers) to obtain an exemption from workers’ compensation coverage requirements on him or herself.  For applicants with an active contractor’s license issued by the Board for Licensing Contractors, the filing fee for an Initial Workers’ Compensation Exemption is $50.00.  For applicants without an active contractor’s license, the filing fee is $100.00 which includes the cost of the Construction Services Provider Registration and the Initial Workers’ Compensation Exemption Registration.  The fee for each Subsequent Workers’ Compensation Exemption Registration is $20.00.  An applicant must be:

  • an individual who is a sole proprietor and owns 100% of the assets of the business,
  • an officer of a corporation,
  • a member of a limited liability company with at least a 20% ownership interest, or
  • a partner in a partnership with at least a 20% ownership interest.

In addition, an applicant may qualify for the exemption if the applicant and members of the same family of the applicant hold at least 95% ownership of the business.  An individual on the registry may voluntarily revoke their exemption at any time by completing a Voluntary Revocation Form (ss-4529) available at http://www.tn.gov/sos/forms/ss-4529.pdf and paying the filing fee of $20.00.

Employers in the construction industry can learn how to become exempt, renew a previously granted exemption and learn more about the program by clicking the link above.  Anyone can search the registry to look for exempt employers by clicking the same link.

For additional information about this topic, please call 615-532-4812 or 1-800-332-2667.

IMPORTANT NOTES:  

  • Registration is available only to individual business owners engaged in the construction services industry, not to business entities.
  • Employees are not eligible for the exemption registry, only employers with an ownership stake in the company.
  • During the application process, a person applying for an exemption must attest that he/she understands that an approved application waives a person’s right to sue under workers’ compensation law if the applicant is later injured on a job.  
  • Exempt employers are still required to cover all of their employees, even if they have only one (1) employee. 
  • Effective October 1, 2011, each corporation, Limited Liability Company, Limited Liability Partnership, Limited Partnership, General Partnership and family owned business may have up to 5 individuals who can qualify to be exempt. A sole proprietor can only have 1 exemption.
  • Exemptions are valid for no less than two years.  All registration notices will include an expiration date.  

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ELECTION OF INSURANCE COVERAGE FORMS

If an employer has five (5) or more employees and its workforce drops below five (5), the employer may elect to drop its workers' compensation coverage if the employer is not in the construction or the coal mining industry.  To drop the coverage, the employer must file a Notice of Withdrawal from Coverage of the Tennessee Workers' Compensation Law (Form I-3) with the Division.  Once the form has been accepted by the Division, the employer will be exempt from the coverage requirements and will not be required to provide workers' compensation coverage while its workforce remains below five employees. 

Corporate officers may exclude themselves from being covered by the workers’ by filing a Corporate Officer Election Not to Accept Provisions of Workers' Compensation (Form I-6) with the Division.  The Form I-6 becomes effective 30 days after the Division of Workers’ Compensation receives the forms.  The original fully-completed notarized form should be sent to the Division.  The I-6 form can be withdrawn by filing a Notice of Corporate Officer’s Revocation of Exemption (Form I-7).  

Employers not required to have workers’ compensation insurance that desire to purchase a policy anyway should file the Exempt Employers Notice of Acceptance of the Workers' Compensation Act of Tennessee (Form I-8) with the Division.  If that employer later decides to drop its workers' compensation coverage, it must file the Exempt Employers Withdrawal of Notice of Acceptance (Form I-9) with the Division.

Most subcontractors are sole proprietors or partners.  Sole proprietors and partners are usually not covered by their workers' compensation policy when it is written; only the employees are covered.  A subcontractor that is a sole proprietor or partner may elect to be covered by his/her own workers' compensation policy by filing an Election of Sole Proprietor or Partner to Come Within the Provisions of the Tennessee Workers’ Compensation Law (Form I-4) with the Division of Workers’ Compensation.  The Form I-4 becomes effective 30 days after the Division of Workers’ Compensation receives the forms.  The original fully-completed and notarized form should be sent to the Division.  The I-4 form can be withdrawn by filing a Notice of Withdrawal of Sole Proprietor or Partner Election (Form I-5).  The I-5 form becomes effective upon the Division’s received stamp date.

A subcontractor, with the agreement of the general contractor, can elect to be covered by the general contractor's workers' compensation insurance by filing an Agreement of General Contractor to Provide Workers’ Compensation Coverage to Subcontractor (Form I-15) with the Division or a subcontractor can have his own workers' compensation coverage and furnish proof of this coverage to the general contractor.   The Form I-15 allows the general contractor to withhold premiums from the subcontractor's payroll to cover the subcontractor and its employees.  The form must be signed by the general contractor and the subcontractor, notarized and filed with the Division.  Failure of the general contractor to file the form with the Division does not relieve the obligation of the insurance company to provide coverage to a subcontractor when the subcontractor can produce evidence of payment of premiums to the insurance company.  The subcontractor, acting as a self-employed individual, is not an employee of the general contractor and might not have coverage as long as he/she is not working as an employee.   There is no form that will waive the rights of employees of subcontractors.  The subcontractor must provide coverage for his employees either through an agreement with the general contractor or by purchasing a separate policy. 

For additional information about this topic, please call 615-532-4812 or 1-800-332-2667.

IMPORTANT NOTES:

  • Sole Proprietors, Partners and Members of LLC’s are excluded from the count of employees that determines whether or not an employer is covered by the Tennessee Workers’ Compensation Act.  Corporate officers are afforded the right to exempt themselves from a workers’ compensation policy, but are NOT excluded from the count of employees unless they are not paid or compensated.
  • Sole Proprietors, Partners and Members of LLC’s must elect coverage by filing Form I-4 with the Division at least 30 days before the occurrence of an injury or death in order to obtain benefits.
  • The election of a corporate officer to be excluded does not reduce the number of employees for the purposes of determining the requirements of coverage. 
  • If an employer files an Exempt Employers Notice of Acceptance of the Workers’ Compensation Act of Tennessee (Form I-8), it will remain subject to the workers' compensation requirements until an Exempt Employers Withdrawal of Notice of Acceptance (Form I-9) is received and accepted by this Division.  If the employer drops its coverage and does not file the Form I-9 and an injury occurs, the employer could be held responsible for providing benefits to the injured employee in that claim.
  • A general contractor can require a subcontractor to have workers' compensation insurance and refuse to sign the Agreement of General Contractor to Provide Workers’ Compensation Coverage to Subcontractor (Form I-15).
  • Failure of the general contractor to file the Form I-15 with the Division does not relieve the obligation of the insurance company to provide coverage to a subcontractor when the subcontractor can produce evidence of payment of premiums to the insurance company. 
  • To view specific rules regarding those engaged in the construction industry, please click here.

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THE RESPONSIBILITIES OF AN INJURED EMPLOYEE

An injured employee should immediately report any work-related accident, injury or illness to their employer.  Employer notification, preferably in writing, is required within thirty (30) calendar days of the date of injury or the date when a physician first tells the employee that his/her injury is work-related. If you are an employee of the State of Tennessee, there are a few differences in the way that your claim is handled. Please check here for information regarding the responsibilities of a state employee. 

Upon the report of a workplace injury, an employer should provide the employee, in writing on An Agreement Between Employer/Employee Choice of Physician (Form C-42)  (*Click here for Spanish version), a list of:

  • At least three physicians;
  • Not associated together in practice together; and
  • Within the community of the injured employee, if available. 
  • If the injury involves the employee’s back, the number of named physicians listed must be expanded to at least four (4) names, one of whom must be a chiropractor. 

The employee has the right to choose a physician from the list.  The physician selected by the employee becomes the “authorized treating physician” and the employee is then required to accept treatment from that physician and should not seek treatment from any other medical provider unless the authorized treating physician makes a referral.   

  • The C-42 form must indicate the name of the physician chosen by the injured employee, be signed by the employee with a copy given to the employee, and the original kept on file with the employer.  Employees may also be asked to sign a Medical Waiver and Consent Form (Form C-31) to allow the employer and/or insurance adjuster to receive copies of medical notes and reports from the chosen physician. 

 

If there are not enough physicians available within the community of the injured worker, names of physicians from outside the community should be added.  Employees traveling more than 15 miles one way to or from medical treatment may seek reimbursement from the insurance carrier for their travel expense. 

For additional information about this topic, please call 615-532-4812 or 1-800-332-2667.

IMPORTANT NOTES: 

  • If a dispute regarding medical treatment or other benefits occurs, an injured employee may seek help resolving the dispute from the Division.  The employee must complete a Request for Assistance Form (C40A) (*Click here for Spanish version) and mail, fax or E-mail to the proper office indicated on the form.
  • To protect his/her rights to benefits, an injured worker must timely submit a completed Request for Benefit Review Conference (Form C-40B(*Click here for Spanish version)
  • The right to receive workers’ compensation benefits does not stay open forever.  In most cases, the deadline to request the benefit review conference is one (1) year from:
    • The date the injury occurred; or,
    • The date the last temporary disability benefits were paid or medical benefits were provided for the injury, whichever is latest. 
  • Employers are not required to pay employees for time spent attending doctor appointments, unless the company has a policy to pay for such time. 
  • Employers or adjusters are generally not required to offer a second panel of physicians or a second opinion.  If requested by the injured employee, however, the insurer or employer MAY agree to provide a second panel.  An employee may always seek a second opinion or obtain treatment with any physician at his/her own expense. 
  • Injured employees must comply with all medical treatment prescribed by the authorized treating physician at all times.  Benefits may be suspended if the injured employee fails to comply with a reasonable request.

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THE RESPONSIBILITIES OF AN EMPLOYER

Employers covered by the Tennessee Workers’ Compensation Act must immediately submit all known or reported injuries or illnesses to their insurance carriers unless the employer is qualified and certified as a self-insured employer.  To learn which employers are covered by the Act, please click here.  Self-insured employers must either report the claim to their Third Party Administrator (TPA) or internal claims handling program.  Reportable workplace injuries or illnesses are those that cause:

  • An employee to receive medical treatment outside of the employer’s premises;
  • Their absence from work, or their retention of a permanent impairment; or,
  • Their death.

WHEN AN EMPLOYEE CLAIMS TO BE AT INJURED WORK, THE EMPLOYER MUST:

  • Fill out a First Report of Injury (Form C-20) and file the form with its insurance adjuster within one (1) working day of its knowledge of the injury.  The claim must be reported to the adjuster even if the employer feels the claim is not work-related.  The insurance adjuster can investigate and deny the claim, if appropriate.
  • Provide the injured employee a panel of at least three (3) physicians, within the community of the injured employee’s home or workplace and not in the same practice, on an Agreement Between Employer/Employee Choice of Physician Form (Form C-42)  (*Click here for Spanish version)   .  If the employer does not have a panel of physicians available at the time the injury is reported, it should immediately call its insurer and develop one.
    • If the injury is to the back, the panel must be expanded to four (4) medical providers and must include a chiropractor.
    • If specialized medical treatment is required, the authorized treating physician may refer the employee for such specialized treatment at which time another panel of specialized physicians should be offered. 
  • Have the employee:
    • Select a physician from the panel; and
    • Sign the form. 

The employer should keep the original form and provide a copy to the employee.  The employer must provide a copy to the Division of Workers’ Compensation upon request.  This selected physician becomes the “authorized treating physician.” 

  • Have the injured employee sign a Medical Waiver and Consent Form (Form C-31).  This form allows the employer, insurance carrier, third party administrator, case manager, utilization review agent and the Division communicate with the treating physician about the treatment for the injury.
  • Assist the employee and/or the insurance adjuster in scheduling the initial appointment and in authorizing medical treatment.
  • Inform the employee of the name and telephone number of the employer’s workers’ compensation insurance carrier and adjuster.
  • Submit a statement of the employee's wages to their workers’ compensation insurance adjuster on a Wage Statement (Form C-41).  The wage statement should show the gross wages earned by the injured employee, including overtime, bonuses, etc., each week for the fifty-two (52) weeks prior to the injury.  If the injured employee has worked for the employer for less than 52 weeks, the statement should show all of the weeks worked and gross wages earned each week.

For additional information about this topic, please call 615-532-4812 or 1-800-332-2667.

IMPORTANT NOTES: 

  • The list of physicians must be provided on the Agreement Between Employer/Employee Choice of Physician Form (Form C-42). Alternative versions of the form are not allowed.
  • The C-42 form designating the chosen physician and signed by the employee is the employer's proof that the employee was offered a choice of physicians.  It must be signed by the employee and dated, indicating the date the physician was selected. 
  • The injured employee’s wages must be provided on the Wage Statement (Form C-41).  Alternative versions of the form are not allowed.
  • Failure to provide a completed Wage Statement to the insurance adjuster could place the employer at risk for being ordered to pay temporary disability benefits to the injured employee at the maximum weekly benefit, which may be an amount higher than would otherwise be due.  That amount can be adjusted by filing a corrected Wage Statement (C41); however, the employer will not receive a credit on future benefits to cover the overpayment.

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FRAUD

It is illegal for any party (the employee, employer, insurance adjuster, or medical provider) to knowingly and intentionally de-fraud another party of a property or monetary gain.  To report workers' compensation fraud, please begin by reporting any information available to the insurance carrier or third party administrator. They should have a process in place for fraudulent claims. The Division cooperates with persons reporting fraud to refer allegations to the appropriate District Attorney General.  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.

For additional information about this topic, please call 615-532-4812 or 1-800-332-2667.

IMPORTANT NOTES: 

  • The Division of Workers’ Compensation does not investigate claims of workers’ compensation fraud.  Anyone wishing to report cases involving issues of fraud should contact the insurance carrier or local District Attorney.

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SECOND INJURY FUND

The purpose of the Second Injury Fund is to encourage employers to hire workers with existing handicaps or permanent disabilities.  If an employee has previously sustained a permanent physical disability from any source, not just a work place injury, and then subsequently becomes permanently and totally disabled due to a workplace injury, the employee is entitled to benefits from the employer at the time of the subsequent injury for that subsequent disability.  The original injury cannot be considered in estimating the compensation due.  After the completion of those benefits, the worker may be entitled to additional benefits paid by the second injury fund.  To claim benefits from the Fund, an employee must prove that he/she previously sustained a permanent disability and that, as a result of a second injury, he/she has become permanently and totally disabled.  The Fund limits the employer's liability to the amount of disability caused by a new, or "second", injury. 

For additional information about this topic, please call 615-532-4812 or 1-800-332-2667.

IMPORTANT NOTES: 

  • Funding for the Second Injury Fund is provided from the workers' compensation premium tax.
  • Tennessee’s Second Injury Fund was established in 1946, following World War II. 

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BENEFITS

Employees who have suffered a compensable workplace injury are entitled to receive the following:
Medical treatment, at no cost to the employee for as long as the authorized treating physician relates it to the work-related injury, including Future Medical Benefits after a claim is resolved.  Medical benefits must be ordered by the authorized treating physician and can include medical/surgical treatment and supplies, medicine, crutches, nursing or psychological services, prescription eyeglass/eyewear, hospitalization, and dental work that is made reasonably necessary by the workplace injury.  Employees traveling more than 15 miles one way to and from medical treatment may seek reimbursement from the insurance carrier for their travel expense. 

Temporary Disability Benefits paid by the insurance company or self-insured employer and are to replace lost wages.  Disability begins only after the authorized treating physician takes an employee off work and these benefits are begin on the eighth (8th) calendar day of the disability.  If the disability lasts fourteen (14) days or more, benefits will be paid back to the first day of disability.  Temporary disability benefits are usually two-thirds (2/3) of the injured worker’s average weekly wages earned during the 52 weeks prior to the injury. 
Payment of Temporary Disability Benefits:  An employee is entitled to 66 2/3% of his/her average weekly wages in temporary total disability (TTD) benefits while taken off work by the authorized treating physician due to the workplace injury, as long as the benefit amount is within the maximum or minimum amounts established by the Tennessee Workers’ Compensation Act.  Click here to see the current maximum and minimum amounts.  The employer must submit a Wage Statement (Form C-41) to the insurance adjuster.  This wage statement will list the injured employee’s gross earnings for the fifty-two (52) weeks prior to the date of injury and should show all earnings including overtime and bonuses.  To determine the benefit, gross earnings are totaled and divided by 52 (the number of weeks in a year).  The result is the employee's average weekly wage.  The average weekly wage is multiplied by .667 to determine the employee's weekly compensation rate. 

During the course of treatment for a work-related injury, the treating physician may determine an injured employee can return to work on “light duty.”  If the authorized treating physician restricts an injured employee’s ability to work, such as limiting the number of hours worked or the type of work performed, it is very important that the physician’s instructions and restrictions are followed at all times.  The employee should get a detailed description of work restrictions from the doctor to provide the employer.  If the employer can provide work within those restrictions, it should do so.  Failure to report for light duty offered by the employer may terminate temporary disability benefits.  If the employee is paid a lesser pay or is restricted to fewer hours because of the light duty, the employee is entitled to "temporary partial disability (TPD) benefits”.  These benefits are figured at 66 2/3% of the difference between the gross light duty wages and the employee’s average weekly wage, subject to the same maximum and minimum workers' compensation rates described above.
            Example:  If an Employee’s average weekly wage were $600.00 per week before being injured, but the same Employee was only able to earn $200.00 per week while on light duty.  The temporary partial disability benefit would be calculated in this manner:
                                       $600.00 minus $200.00 equals $400.00 difference in pay due to the light duty restrictions.
                                       66 2/3% of $400.00 equals $266.68.
            Therefore, the Employee will earn $200.00 in wages and would receive $266.68 in workers' compensation temporary partial disability benefits.  However, if the employer is unable to meet the restrictions provided by the treating physician, the injured employee would remain off work and his/her temporary total disability benefits described above would continue. 
Stopping Benefits:  There are several circumstances under which the temporary disability benefits stop.  They include:

  • When an injured employee is released by the authorized treating physician to return to work without restrictions.
  • If an injured employee refuses to comply with a reasonable request for medical examination or to accept medical treatment, compensation may be stopped for the period of time an employee continues the refusal.
  • If the employer or insurance carrier has been paying benefits and discovers those payments were made in error, the insurance carrier can stop benefit payments; but, must file a Notice of Controversy (Form C-27).
  • When an injured employee’s treating physician determines the employee has reached maximum medical improvement (MMI), and the compensability of the injury has not been contested.  Payments must continue until the earlier of the following events:
      • An injured employee accepts or rejects a job offered by the employer at a wage equal to or greater than the employee's pre-injury wage; or,
      • A Benefit Review Conference is held and a report is filed by the Division.

Permanent Disability Benefits:  When the injury has healed and maximum medical improvement (MMI) is reached, the injured employee will likely be released from the treating physician's care and may be referred for other additional services such as physical therapy, pain management and possibly work hardening sessions.  The authorized treating physician may assign a permanent impairment rating based on the applicable edition of the American Medical Association Guides to the Evaluation of Permanent Impairment.  To find the applicable edition of the Guides, click here.  The impairment rating, combined with vocational factors, may result in a permanent disability award.  Workers' Compensation Specialists with the Division conduct, at no cost to the parties, informal Benefit Review Conferences to assist the parties in reaching a final agreement or settlement of the claim. The Benefit Review Conference is discussed below.  Attorney Specialists with the Division may approve settlement agreements with respect to permanent disability and death benefits, including the issues of future medical benefits where provided for by statute.  No settlement will be approved that does not provide that the employee is receiving substantially the benefits to which he/she is entitled.  In cases where there is a dispute between the parties as to whether a claim is compensable or as to the amount of compensation due the Attorney Specialists may approve a settlement on a “doubtful and disputed” basis without regard to whether the employee is receiving substantially the benefits to which he/she is entitled if the settlement is determined to be in the best interest of the employee. 

Permanent Partial Disability describes the condition of an employee able to return to a job in the open market, but who retains a permanent disability because of a work-related injury.  That employee may be entitled to Permanent Partial Disability benefits.  The benefit is 66 and two-thirds percent (66 2/3%) of the injured employee’s average weekly wage, subject to limitations depending upon the body part affected by the work-related injury (for injuries before July 1, 2014), and the employee’s ability to return to his/her prior employment.  This benefit continues until he/she becomes eligible for old age retirement under the social security law.

          Death Benefits:  When a compensable workplace injury results in the death of a covered employee, benefits are available to the surviving dependents.  Burial expenses for the deceased employee are paid, not to exceed $7,500.  When the deceased employee leaves no dependents, $20,000 shall be paid to his or her estate.  If an employee leaves a surviving spouse and no dependent child, fifty percent (50%) of the average weekly wages shall be paid to the surviving spouse subject to the maximum weekly benefit (400 weeks).  If an employee leaves a surviving spouse and one or more dependent children, sixty-six and two-thirds percent (66 2/3 %) shall be paid to the surviving spouse for the benefit of the surviving spouse and dependent child(ren).

For additional information about this topic, please call 615-532-4812 or 1-800-332-2667.

IMPORTANT NOTES: 

  • If the injured employee has worked for his/her employer for less than 52 weeks at the time of the injury, the weekly compensation rate must be figured by one of the following two methods: 
  • By counting the number of weeks the injured employee has worked for that employer and calculating gross earnings for those weeks.  The gross earnings are divided by the actual number of weeks employed with that employer; or,
  • By calculating the average weekly wage earned by a similar worker employed with the same employer performing the same job as the injured employee during the 52 weeks prior to the injury.
  • Temporary disability payments for a compensable work-related injury or illness must be paid by the insurance company and received by the injured employee no later than fifteen (15) days after notice of injury.  All workers’ compensation benefits shall be issued timely to assure the injured employees receive the benefits on or before the date they are due.  Unpaid or untimely paid benefits may be subject to a penalty.

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MEDICAL CASE MANAGEMENT

The purpose of the Medical Case Management Program is to help coordinate the medical diagnostic and treatment services provided to injured employees for their work-related injuries.  This is done to promote the most cost-effective medical treatment without compromising the patient's quality of care.  Employers or insurance adjusters may, at their own expense, utilize case management but it is not required. If utilized, injured workers must cooperate with the case manager.  Case Management services shall include, but not be limited to:

  • The development of a treatment plan to provide appropriate medical services;
  • The monitoring the treatment and medical progress;
  • Assessing whether medical services are appropriate and delivered in a cost-effective manner, based on acceptable medical standards;
  • Ensuring that the injured employee is following the prescribed medical care plan; and,
  • Formulating a plan for return to work, with due regard for the employee's recovery, restrictions, and limitations, if any.

For additional information about this topic, please call 615-532-4812 or 1-800-332-2667.

IMPORTANT NOTES: 

  • The use of a medical case manager is voluntary and at the discretion of the insurance carrier/employer.
  • Case Managers must register with the Division prior to providing services involving Tennessee Claims using this form:  ../forms/c38.pdf. 

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FUTURE MEDICAL BENEFITS

Employees who have suffered a compensable workplace injury are entitled to receive continuing medical benefits for treatment that is related to that workplace injury after a final settlement has been reached or a trial has been conducted on the merits of the case.  These future medical benefits, available at no cost to the employee, are provided for as long as required by the authorized treating physician. Medical benefits ordered by the authorized treating physician can include medical/surgical treatment and supplies, medicine, crutches, nursing or psychological services, prescription eyeglass/eyewear, hospitalization, and dental work that is made reasonably necessary by the workplace injury.

If an employee is having difficulty receiving his/her future medical benefits they should submit a Request for Assistance Form C-40A (*Click here for Spanish version).  The process to resolve the dispute begins when the form is completed and received by the Division.  When the form is received, it will be assigned to a Mediating Specialist in the area office closest to the injured employee’s home address.  The Mediating Specialist will attempt to communicate with all parties to learn about their individual concerns and positions.  If the issue(s) cannot be resolved through this mediation, the file is transferred to an Attorney Specialist who has the authority to resolve the issue(s) with the issuance of a Benefit Review Order either denying or awarding the requested benefits. 

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THE UTILIZATION REVIEW (UR) PROGRAM

Utilization Review is the evaluation, by an outside source, of the necessity, appropriateness, efficiency, and quality of medical care services provided to an injured employee.  It is required when:

  • The medical necessity of a treatment recommended by an authorized treating medical provider is disputed by the insurance adjuster; and,
  • In instances required by the workers’ compensation statutes or medical fee schedule (e.g., hospital admissions, physical or occupational therapy, chiropractic care, clinical psychological treatment). 

UR provides for the review of selected outpatient and inpatient health care providers and pre-admission review of all hospital admissions, except for emergency services. 

Recommended medical treatment(s) may be approved by the insurance adjuster, a registered nurse or an Advisory Medical Practitioner, which is an actively TN-licensed practitioner, who is board-certified and in the same or similar general specialty as the authorized treating physician.  An adjuster cannot deny a recommended treatment as not being medically necessary.  The recommended treatment can only be denied by an Advisory Medical Practitioner. 

  • The adjuster has three (3) business days after being notified of the recommended treatment to approve the treatment or send the recommendation to its utilization review agent. 
  • The utilization review agent has seven (7) business days to make a decision on the recommended treatment and notify all parties of the decision. If the utilization review agent does not possess all necessary information in order to render the utilization review determination, then they shall request additional information, in writing, from the authorized treating physician, who shall comply with the request within five business days of receipt of the written request. The number of business days is extended until the utilization review agent receives the necessary information or until the five (5) business day timeframe expires, whichever occurs first.
  • The decision reached by the utilization review agent can only address medical necessity and not causation and/or compensability.  An approval of the treatment by the utilization review agent is final and not subject to appeal.
  • If an authorized treating physician has sought to provide specific medical treatment, but the treatment has been denied by the employer through a utilization review process, injured workers should seek the assistance of this program.  Denials of recommended treatment must be accompanied by a utilization review report that gives the reasons for denial and contact information for the utilization review physician.  Denials must also be accompanied by an Utilization Review Appeal Form (Form C-35A) so the injured worker, their attorney and treating physician are informed of the proper procedure to request an appeal with the Division.  
  • After a denial, the injured worker, their attorney or treating physician has thirty (30) calendar days from receipt to appeal the utilization review decision to the Division at the address listed on the form.  After a complete medical record is received, the Division of Workers’ Compensation’s Medical Director, or his/her designee, will determine if he/she agrees with the insurance carrier’s utilization review denial.  If the Medical Director, or his/her designee, disagrees with the utilization review decision, an order for the treatment recommended by the authorized treating physician will be issued.

To view the Utilization Review Program Rules, click here.

For additional information about this topic, please call 615-532-4812 or 1-800-332-2667.

IMPORTANT NOTES: 

  • UR services must be provided or contracted for/by each insurer who provides workers' compensation insurance in Tennessee as well as every self-insured employer.  The self-insured employer may choose to provide the services itself or through a third party administrator. 
  • The UR Agent conducting the review services for the employer must be registered with the Division of Workers’ Compensation and the Tennessee Department of Commerce and Insurance.
  • A health care provider who is found to have rendered excessive or inappropriate services may be subjected to:
    • Forfeiture of the right to payment for the services rendered;
    • Payment of civil penalty of not less than $100.00 nor more than $1,000.00; or,
    • Temporary or permanent suspension of the right to provide medical care services for workers' compensation claims if the healthcare provider has established a pattern of violations.
  • An employer, insurer, third party administrator, or UR Agent who is found to have violated the UR rules may be subjected to a penalty of not less than $100 nor more than $1,000 per violation.  The Division may also institute a temporary or permanent suspension of the right to perform utilization review services for workers’ compensation claims, if the utilization review agent has established a pattern of violations.

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MEDIATION AND THE BENEFIT REVIEW PROGRAM

The Benefit Review Program administers an assistance and mediation program for disputed issues in a workers’ compensation claim.  To view the Benefit Review Program Rules, click here.

REQUEST FOR ASSISTANCE PROCESS
The first stage of this program is the Request for Assistance (RFA) process.  It is designed to resolve disputes or problems between injured workers and an insurance adjuster or employer regarding a workplace injury that involve medical or temporary disability payment benefits.  If an injured worker is having difficulty receiving temporary disability payment benefits or medical treatment related to a workplace injury then they can seek assistance with resolution of those issues by submitting a Request for Assistance Form C-40A (*Click here for Spanish version). 

When the Form C-40A is received, it will be assigned to a Mediating Specialist in the area office closest to the injured worker’s home address.  The assigned Mediating Specialist is not a legal representative for the employee or employer.  Instead the mediator serves a neutral role and will attempt to resolve the disputed issues by seeking a voluntary agreement from the parties.  This agreement can be achieved by communicating with the parties to learn about their individual concerns and positions.  If the issue(s) cannot be resolved through this initial mediation process, the file is transferred to an Attorney Specialist who has the authority to resolve the issue(s) with the issuance of a Benefit Review Order either denying or awarding benefits. 

THE BENEFIT REVIEW CONFERENCE (BRC) PROCESS
The second stage of the process can occur if the injured worker has a permanent impairment from the workplace injury and is scheduled after the injured worker is placed at maximum medical improvement (MMI) by the authorized treating physician.  This stage is the Benefit Review Conference (BRC).  The BRC is simply a mediation involving permanent disability considerations and future medical treatment.  Once the injured worker reaches a medical plateau, often referred to by the treating physician as “maximum medical improvement” or MMI, this mediation can be requested by either party to the claim.  

The Benefit Review Conference (BRC), or mediation, is designed to help speed-up the settlement process and make it less costly to the parties by resolving the matter through an alternative dispute resolution rather than through the court system.  If the injured worker has reached MMI and is ready to settle the issues regarding his/her workplace injury, he/she will need to complete and submit the Request for Benefit Review Conference Form C-40B (*Click here for Spanish version).  Typical issues resolved in a BRC include the injured employee’s right to future medical treatment and the amount of any Permanent Disability Benefits due the employee.

A settlement may be reached through a BRC involving a Mediating Specialist with the Division of Workers’ Compensation or by outside negotiations and agreement of the parties.  Terms of the settlement are included in a written Settlement Agreement that must be approved in order to become a binding legal document.  The Division conducts Approval Conferences, in which a staff Attorney Specialist reviews the terms of the settlement with the injured worker, ensuring that the terms agreed to within the document are fair and equitable to all sides.  The approval process has the same standing as if it were approved through a Court proceeding.
For additional information about this topic, please call 615-532-4812 or 1-800-332-2667.

IMPORTANT NOTES: 

  • The Division has established a goal of resolving disputes handled through the Request for Assistance process within 60 days.  Orders issued in this process can be appealed to the Administrative Review Program, described below, if either party thinks the Order was unjust.
  • The right to receive workers’ compensation benefits does not stay open forever.  To protect his/her rights, an injured worker must request a Benefit Review Conference by completing a Request for Benefit Review Conference Form C-40B (*Click here for Spanish version).  In most cases, the deadline to request the conference is one year from:
    • The date the injury occurred; or,
    • The date the last temporary disability benefits were paid or medical benefits were provided for the injury, whichever is latest. 
  • The designated Discovery Attorney is a statutorily-created position, authorized to resolve disputes between parties regarding exchange of information in a workers’ compensation claim that has not been filed in court.  The attorney may issue subpoenas, effect discovery, and issue protective orders where appropriate.
  • The parties must comply with a Benefit Review Order within fifteen (15) calendar days.
  • Benefit Review Conferences cannot be conducted until after an injured worker reaches MMI. 
  • The Benefit Review process must be exhausted prior to either party filing a lawsuit.  The process is exhausted if the claim is denied on compensability by a staff Attorney Specialist or if a Benefit Review Conference is requested and conducted. 

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THE ADMINISTRATIVE REVIEW PROGRAM

The Administrative Review Program provides an independent review of a Benefit Review Order.  If the injured employee, employer or insurance adjuster disagrees with an Order issued by a Benefit Review Attorney Specialist, he/she may request an Administrative Review of the Order.  Once requested, an Administrator’s Designee will review all of the information and documentation in a case file and conduct an informal conference before making a decision and issuing a new order.   The Program’s goals are to assure that Orders, whether awarding or denying benefits, are in accordance with the applicable Workers’ Compensation Law, rules and regulations, policies and procedures, as well as case law to provide a more informal and cost-effective appeal process than through the state’s Court system. The administrative review is conducted by a Workers’ Compensation Attorney Specialist, known as an Administrator’s Designee, in an expedited and efficient Informal Conference over the telephone in which each party is able to explain the facts and issues involved in their workers’ compensation matter.  Either party may request the review by submitting a Request for Administrative Review Form C-44 within seven (7) calendar days of his/her receipt of the Benefit Review Order.

For additional information about this topic, please call 615-532-4812 or 1-800-332-2667.

IMPORTANT NOTES: 

  • An Informal Conference is conducted within ten (10) calendar days from the date the Division receives the Request for Administrative Review Form C-44 unless otherwise agreed by both parties.  The conference is a telephone conference call for the parties to explain the facts and issues of their workers’ compensation matter to a senior member of the Division.
  • General information that was available and could have reasonably been obtained and provided by a Party to the Benefit Review Specialists before the Benefit Review Order was issued will not be considered by Administrative Review except in very limited circumstances.
  • The Division must produce a new Order within seven (7) calendar days of the Informal Conference.
  • The parties must comply with the new Order within ten (10) calendar days of the receipt of the decision.

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THE MEDICAL IMPAIRMENT RATING REGISTRY (MIR) PROGRAM

The Medical Impairment Rating (MIR) Registry is a Division of Workers’ Compensation-maintained listing of qualified and approved physicians who are specially trained to conduct impairment rating medical evaluations and who have applied to serve on the Registry.  The program is designed to assist parties in settling a workers’ compensation claim when the only item being disputed is the impairment rating.  The program provides the names of physicians, listed on the Registry, who are specifically trained in the techniques of performing impairment rating evaluations on the body part(s) involved in the workers’ compensation claim.  The physicians whose names are provided will be objective and impartial since they will not have been involved in the claim whatsoever.  The rating produced by the physician selected by the parties is utilized to help determine any Permanent Disability Benefits due in the matter.

Before the parties can request a MIR evaluation, there must be a dispute about the impairment rating.  A dispute occurs when:

  • There are competing impairment ratings issued by different physicians, and the parties disagree as to which rating is correct (dueling doctors), or
  • The treating physician has placed permanent restrictions on the claimant, but has issued a rating of “zero,” or states that there is “no permanent impairment.”
  • To request the MIR evaluation, one of the parties must submit the Application for a Medical Impairment Rating (MIR) form to the division.

The Program is designed to increase the number of cases being settled outside the courts.  It is quicker, less expensive and adds consistency and predictability to the system when compared to having the issue resolved in court.    

For additional information about this topic, please call 615-532-4812 or 1-800-332-2667.

IMPORTANT NOTES: 

  • The program is available only for dates of injuries on/after July 1, 2005.
  • An MIR evaluation may be requested by either party.  Regardless of which party requests it, the cost of the evaluation is borne by the employer.
  • To help eliminate some of the unproductive negotiations and unnecessary lawsuits, opinions that physicians issue in MIR evaluations are considered, by statute, to be “accurate” and can be overcome only by clear and convincing evidence to the contrary.
  • The report provided by the MIR physician will provide only the impairment rating.  It will not address causation, apportionment, job restrictions or modifications, or the appropriateness of treatment.
  • Injuries occurring on or after January 1, 2008 must be rated by The AMA Guides to the Evaluation of Permanent Impairment, 6th Edition
  • Injuries occurring prior to January 1, 2008 must be rated by the applicable version of the AMA Guides, as determined by the Tennessee Workers’ Compensation Act.

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SAFETY COMMITTEES

                                  
Promoting workplace safety is an important priority of the Division of Workers’ Compensation, just as it is for the entire Department of Labor and Workforce Development.  And, we are confident that Tennessee employers share our interest.  Injury prevention is perhaps the single most effective method of cost containment; it's also very good business.  Experience has proven conclusively that a properly endorsed and administered safety program will reduce both the number and severity of injuries in the workplace.  Consequently, Tennessee initiated a Safety Committees program in 1992 to emphasize the promotion of safety and health in the workplace.  The provisions of this program encourage every employer to establish and administer a safety committee according to guidelines developed by the Department. 

For additional information about this topic, please call 615-532-4812 or 1-800-332-2667.

IMPORTANT NOTES: 

  • Every employer whose workers’ compensation experience modification factor is 1.20 or greater is required to establish and administer a safety committee in the workplace that must be maintained for as long as the experience modification factor remains at 1.20 or greater.  The purpose of the safety requirements is twofold:
    • To prevent as many accidents and injuries in the workplace as possible.
    • To reduce the severity of the accidents and injuries which do occur in the workplace.

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DRUG FREE WORKPLACE PROGRAM

The Tennessee Drug Free Workplace Program is designed to increase productivity for Tennessee employers and promote safe worksites for employees by promoting drug- and alcohol-free workplaces.  Worksites where workers are not impaired by drugs and alcohol are safer worksites and can operate in an enhanced competitive position that is free from the costs, delays and tragedies that accompany workplace accidents resulting from substance abuse related injuries.  Employers are not required to join; and if the reasons named above are not reason enough, there are several other benefits an employer should contemplate when considering participation.  An employer certified by the Program to be Tennessee Drug Free participant is entitled to:

  • A 5% premium credit on its workers' compensation insurance policy. 
  • A shift in the burden of proof in workers’ compensation claims involving a positive alcohol or drug test. If an employee is injured at work and later fails a post-accident drug/alcohol test, it is presumed that the drugs or alcohol were the proximate cause of the injury.  Workers’ Compensation benefits can be denied until the injured employee overcomes that presumption. 
    • Legislation was passed in 2011 that increased the standard of proof required by an injured worker to overcome the presumption from a preponderance of evidence to clear and convincing evidence.  This change makes it even more difficult for employees impaired by alcohol or other drugs, while at work, to qualify for workers’ compensation benefits. 
  • The presumption that the discharge or discipline of an employee, or the refusal to hire a job applicant, who is found to be in violation of the employer’s drug-free workplace program will be considered done for cause.  This will likely disqualify employees from receiving unemployment benefits.

For additional information about this topic, please call 615-532-4812 or 1-800-332-2667.

IMPORTANT NOTES: 

  • Participating employers are required to renew their application each year at the same time that they renew their workers’ compensation insurance policy.
  • Participating employers are required to administer the following five types of tests:
    • Pre-employment (must test for drugs, may test for alcohol) after a conditional offer of employment
    • Post-accident that resulted in an injury—in emergency situations employees injured and required to be tested must be taken to a medical facility for immediate treatment of the injury.  Specimens cannot be taken prior to administering emergency care.  In non-emergency situations the injured employee must submit to the test at the time the injury is entered into the employer’s OSHA 300 log.
    • Reasonable suspicion—employer must detail in writing, within seven (7) calendar days, the circumstances that formed the determination to test and provide a copy of this detail to the employee upon request
    • Fitness-for-duty (for safety-sensitive positions)—where required by law; are part of the employer’s policy; or is routinely scheduled for all members of the employment classification group;
    • Follow-up testing of employees that enter an EAP program for drug/alcohol-related reasons—not required if employee voluntarily entered program; if required it must be conducted at least once a year for two consecutive years; employee cannot be given advance notice of the date of the follow-up test
  • Employers are allowed, but not required, to do random testing.
  • Testing facilities must be licensed and approved by the TN Department of Health or the US Dept. of Health and Human Services (HHS), College of American Pathologists, or other recognized authority authorized by the Commissioner.  The lab must comply with the procedures established by the federal DOT.  Labs that perform confirmation tests must also be certified by either the Substance Abuse or Mental Health Services Administration (SAMSHA) or by the College of American Pathologists—Forensic Urine Testing Programs (CAP-FUDT). 

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