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Workers' Compensation Division - Medical Providers Information

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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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:  http://www.tn.gov/labor-wfd/forms/c38.pdf. 

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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.
To view the Utilization Review Appeal Fee Notice, 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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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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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)  (*Click here for Spanish version) . 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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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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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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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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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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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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