Tennessee
UTILIZATION
REVIEW AND PRIOR AUTHORIZATION REQUIREMENTS
WORKERS’
COMPENSATION STATE LAW AND REGULATIONS*
*Please Note: This document was created in May, 2009. For the most up to date information, please contact
Medtronic State Government Affairs at 763-526-8195 or at preservingtherapyaccess@medtronic.com. The
content provided on this document is intended as general educational information, not legal, medical, or other
professional advice. Individual situations and state laws vary, and users are encouraged to obtain appropriate
advice from qualified professionals in the applicable jurisdictions.
The commissioner of labor and workforce development shall establish a system of
utilization review of selected outpatient and inpatient health care providers to employees
claiming benefits under this chapter, by providers qualified pursuant to law or the
utilization review accreditation commission.
The commissioner shall also establish a system of pre-admission review of all hospital
admissions, except for emergency services;
Pursuant to the commissioner's established system of utilization review, the
commissioner may contract with an independent utilization review organization, not
owned by or affiliated with any carrier authorized to write workers' compensation
insurance in the state, to provide utilization review, including peer review.
Nothing shall prevent an employer from electing to provide utilization review; however,
if the employee, provider or any other party not contractually bound to the employer's
utilization review program disagrees with that employer's utilization review, then that
employee, provider or other party shall have recourse to the commissioner's utilization
review program, as provided for in this section.
Tennessee Code § 50-6-124.
http://www.michie.com/tennessee/lpext.dll?f=templates&fn=mainh.htm&cp=tncode
Definitions:
"Director" means the Director of the workers' compensation division.
"Health care provider" means any licensed individual or entity which renders health care
services, including but not limited to, chiropractors, physical therapists, physicians,
surgeons, and hospitals.
"Medical Director" means the medical Director appointed by the Commissioner of Labor
"Utilization review" means "utilization review" as defined in T. C. A. §50-6-102( a)
[Section 2 of Public Chapter 900].
UR for Workers’ Compensation:
Each insurer who provides workers ‘compensation insurance or self-insured employer
shall provide for a system of utilization review for cases involving compensable injuries.
Utilization review conducted pursuant to these rules shall comply with the requirements
of T. C. A., Title 56, Chapter 6, part 7*. Any insurer providing workers' compensation
insurance under T. C. A., Title 50, Chapter 6, shall provide or contract for utilization
review services for workers' compensation cases.
The insured employer may choose to provide the required utilization review services on
its own or through a third party administrator. If so, the insured employer shall inform its
insurer in writing of its choice and the insurer is relieved of its duty to provide utilization
review services.
The Commissioner of Labor shall provide or contract for certain utilization review
services. The state utilization review services provided or contracted for shall include,
among other things, providing:




A review of an individual case when a employee, employer, or health care provider, seeks an appeal; Review of utilization review services provided by other utilization review agents or firms for workers' compensation cases; Identification of providers who may have rendered excessive or inappropriate services to the Commissioner for appropriate action; and Development of reports and summaries of utilization of medical care and services in workers' compensation cases in Tennessee or any political subdivision of the state. Any organization conducting utilization review for workers' compensation cases pursuant
to these rules shall provide to the Director of Workers' Compensation copies of any
information provided to the Commissioner of Commerce and Insurance pursuant to T. C.
A. §56-6-704.
PRE-ADMISSION REVIEW
Subject to the requirements of T. C. A. §56-6-705*, each employer or the employer's
insurer covered by those rules shall establish and maintain a system of preadmission
review of in-patient hospital care in non-emergency cases for employees claiming
benefits under the Workers' Compensation Law. In emergency cases, the hospital shall
notify the employer's utilization review agent or the Department of Labor's utilization
review program within one (a) working day of admission. In non-emergency cases,
planned or elective hospital admissions shall be reviewed for medical necessity prior
to admission.
Any health care provider, excluding hospitals, ordering the admission of an injured or
disabled worker for evaluation or treatment of his or her injury or occupational disease
disablement shall report to the employer's utilization review provider, at least forty-eight
(48) hours prior to any overnight admission, all the information required by the Rule
with regard to planned overnight admissions of injured or disabled workers.
Any health care provider or hospital discharge planner ordering or arranging a transfer of
an injured or disabled worker to another inpatient facility shall report to the employer's
utilization review provider, at least twenty-four (24) hours prior to any transfer, all
information required by this chapter with regard to planned overnight admission of
injured or disabled workers; provided, however, that the hospital discharge planner, if
any, shall be primarily responsible for satisfaction of this requirement.
If adequate information has been provided, the employer's utilization review provider
shall:
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

Render a decision concerning the necessity, appropriateness and length of stay of the proposed admission based upon medically accepted standards and an objective evaluation of the circumstances of the proposed admission; Verbally notify the hospital, payer and health care provider ordering the admission of its decision prior to the commencement of the proposed admission; and Transmit written notification to the hospital, payer and health care provider ordering the admission within twenty‐four (24) hours of its decision. If the employer's utilization review provider does not possess adequate information to
render its decision prior to admission, the employer's utilization review provider shall
verbally inform the hospital, health care provider and payer that it is unable to render a
decision. The employer's utilization review provider shall, prior to the proposed
admission, issue a written report to the hospital, health care provider, payer and workers'
compensation division of all failures to provide information that is adequate to allow it to
render a decision.
Throughout the period of time in which inpatient services are being provided to the
injured or disabled worker, the employer's utilization review provider shall monitor the
injured worker's condition, treatments, procedures and length of stay for medical
necessity and appropriateness. All health care providers are required to cooperate with
the contractor and employer's utilization review provider for concurrent review of
hospitalization and are required to provide, without additional charge to any party, any
available medical information requested by the contractor or employer's utilization
review provider for that purpose. Any dispute concerning the reasonableness of the
request for information by the employer's utilization review provider or contractor for
purposes of concurrent review shall be determined by the Director upon the written
request of any party. All determinations of the Director pursuant to this chapter shall be
final.
APPEALS OF CERTIFICATION DECISIONS
Any party aggrieved of a decision of the employer's utilization review provider
concerning pre-admission, outpatient or inpatient review certifications, who has appealed
such decision under the appeal procedure established pursuant to T. C. A. §56-6-705,
may request in writing that the medical Director review the employer's utilization review
provider's decision concerning certification or denial of hospitalization. With the
assistance of the contractor, as needed, the medical Director shall obtain a second
medical opinion by its peer review consultant with respect to such requests for review
and shall expeditiously respond, in writing, to the injured or disabled worker, employer,
insurer, hospital, health care provider and third party administrator, if any, concerning the
results of its review.
Tenn. Comp. R. & Regs. 0800‐2‐6‐.02 http://www.tennessee.gov/sos/rules/0800/0800‐02/0800‐
02‐06.pdf *56‐6‐705. Utilization review agents — Minimum standards. — http://www.michie.com/tennessee/lpext.dll?f=templates&fn=main-h.htm&cp=tncode
All utilization review agents shall meet the following minimum standards:
Notification of a determination by the utilization review agent shall be mailed or otherwise communicated to the provider of record or the enrollee or other appropriate individual within two (2) business days of the receipt of the request for determination and the receipt of all information necessary to complete the review; Any determination by a utilization review agent as to the necessity or appropriateness of an admission, service, or procedure shall be reviewed by a physician or determined in accordance with standards or guidelines approved by a physician; Any notification of determination not to certify an admission or service or procedure must include the principal reason for the determination and the procedures to initiate an appeal of the determination; Utilization review agents shall maintain and make available a written description of the appeal procedure by which the enrollee or the provider of record may seek review of a determination by the utilization review agent. The appeal procedure shall provide for the following: 
On appeal, all determinations not to certify an admission, service, or procedure as being necessary or appropriate shall be made by a physician in the same or a similar general specialty as typically manages the medical condition, procedure or treatment under discussion as mutually deemed appropriate. For mental health and chemical dependency care, the person performing the utilization review in these appeal determinations must be both licensed at the independent practice level and in an appropriate mental health or chemical dependency discipline like that of the provider seeking authorization for the care denied; 
Utilization review agents shall complete the adjudication of appeals of determinations not to certify admissions, services, and procedures no later than thirty (30) days from the date the appeal is filed and the receipt of all information necessary to complete the appeal; and 
When an initial determination not to certify a health care service is made prior to or during an ongoing service requiring review, and the attending physician believes that the determination warrants immediate appeal, the attending physician shall have an opportunity to appeal that determination over the telephone on an expedited basis. A representative of a hospital or other health care provider or a representative of the enrollee or covered patient may assist in an appeal. Utilization review agents shall complete the adjudication on an expedited basis. Utilization review agents shall complete the adjudication of expedited appeals within forty‐eight (48) hours of the date the appeal is filed and the receipt of all information necessary to complete the appeal. Expedited appeals which do not resolve a difference of opinion may be resubmitted through the standard appeal process; Utilization review agents shall make staff available by toll‐free telephone at least forty (40) hours per week during normal business hours; Utilization review agents shall have a telephone system capable of accepting or recording incoming telephone calls during other than normal business hours and shall respond to these calls within two (2) working days; Utilization review agents shall comply with all applicable laws to protect the confidentiality of individual medical records; Physicians or psychologists making utilization review determinations shall have current licenses from a state licensing agency in the United States; Utilization review agents shall allow a minimum of twenty‐four (24) hours after an emergency admission, service, or procedure for an enrollee or the enrollee's representative to notify the utilization review agent and request certification or continuing treatment for that condition; and The commissioner shall exempt from these standards any utilization review agent who has received accreditation by URAC or the national committee for quality assurance. Summary from URAC:
The Division of Workers’ Compensation within the Tennessee Department of Labor and
Workforce
Development administers the state’s Workers Compensation Law (Tennessee Code
Annotated §50-6-
101). Section 50-6-124 directs the Commissioner to establish a system of utilization
review of health care providers to workers’ compensation claimants “by providers
qualified pursuant to law or the utilization review accreditation commission” (URAC).
The Rules of the Department’s Division of Workers’
Compensation addresses utilization review in Chapter 0800-2-6. Section 0800-2-6-.02
requires workers’ compensation insurers and self-insured employers to provide for
utilization review for cases involving compensable injuries. Utilization review conducted
pursuant to these rules must comply with the state’s Health Care Service Utilization
Review Act (T.C.A. §56-6-701). The Act, implemented by the Tennessee
Department of Commerce and Insurance, requires UR agents to meet the minimum
standards set forth in
§56-6-705, but directs the Commissioner to exempt from these minimum standards any
UR agents that are URAC accredited (§ 56-6-705b).