Transcript Tennessee Business Institute

What’s Going On At The
Workers’ Compensation Division
Our Mission
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To promote the benefits and
responsibilities of the Workers’
Compensation Act
To make available the services
provided by the Act
To act in a manner that is fair,
consistent, professional, and
impartial to everyone
Profile of WC in Tennessee
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Court administered
Regulatory and administrative
responsibilities divided
– Department of Commerce and
Insurance
– Department of Labor and Workforce
Development
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Workers’ Compensation law is a
compromise between employer and
employee
Claims
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Employers obligated by Law
– To provide all medical services
– Present panel of three physicians, except if
back injury, panel of physicians must be
expanded to four, with one being Doctor of
Chiropractic
– Indemnify lost wages to employee
– Compensate permanent impairment
– Report injuries / occupational illnesses to
Division; this includes lost time and medical
only claims
– Process all claims according to Claims
handling standards
Claims, continued
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Employees required by Law
– To report injury to employer within 30
days
– Select an “authorized treating
physician”
– Follow medical provider’s instructions
– Cooperate with all parties
EDI
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Electronic Data Interchange (EDI)
Process
– Employer reports all lost time and medical only claims
to Claims administrator in the usual manner.
– Claims Administrator reports the claim to Tennessee
electronically.
– Tennessee receives the claim transaction and returns
an acknowledgment transaction to the Claims
administrator.
– The acknowledgment transaction notifies the Claims
administrator that the transaction was received and
tells if the transaction was accepted or rejected. If
rejected, information about the rejection is included in
the acknowledgment.
– The acknowledgment transaction returns the State File
Number (called the Agency Claim Number or ACN) to
the Claims administrator.
EDI, continued
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The Division is no longer accepting paper forms
on the following:
– First Report of Injury (C-20)
– Notice of First Payment of Compensation (C-22)
– Notice of Denial of Claim for Compensation (C-23)
However, a paper copy of the form with reason for
denial or a copy of denial letter is required
– Notice of Change or Termination of Compensation
Benefits (C-26)
– Final Report of Payment (C-29)
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Detailed information available by emailing a
request to [email protected]
Employer Requirements
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Every employer who has five (5) or more
employees is required to have workers’
compensation coverage; except that any
employer in construction industry or
engaged in mining & production of coal
who has one (1) or more employees is
required to have coverage
Some employers and employees are not
covered by the Law
State and local governments are exempt
from the Law
Coverage
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Every employer subject to law is
required to provide coverage
Three types of coverage
Every employer required to provide
proof of coverage
Every employer required to display
Tennessee Workers’ Compensation
Insurance Notice
Uninsured Employer Fund
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Investigates and penalizes
employers who fail to have workers’
compensation coverage
Goals
Penalty Process
Injunction
Benefit Review
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Purpose
– To resolve disputes
– To minimize adversarial relationships
– Decrease litigation
– Reduce overall costs of claims
Benefit Review
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Staff
– Workers’ Compensation Representatives
– Workers’ Compensation Specialists
– Administrative Support Staff
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Locations (Six area offices):
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Nashville
Memphis
Jackson
Knoxville
Chattanooga
Kingsport
Benefit Review
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Workers’ Compensation
Representative Functions
– Toll-free number: 1-800-332-2667
– General Information about workers’
compensation
– Initial Dispute resolution
– Send Request for Assistance
Benefit Review
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Workers’ Compensation
Specialist Functions
– Temporary Disability & Medical
Treatment Issues
– Mediation of Permanent Disability
Issues
– Approval of Settlements
Benefit Review
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Request for Assistance
– Statute of Limitations is Tolled
– Handled in area where employee lives
– Establishes a State File Number
Medical Case Management
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Definition
Thresholds
Qualifications
Elements
Utilization Review
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Provisions
Requirements
Permanent Total Disability
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An employee determined to be
permanently totally disabled by trial
or settlement may be reexamined
after twenty-four months from the
entry date of the final order.
Each year an employee who is
receiving permanent total disability
benefits is required to certify that
he/she continues to be permanently
totally disabled
Medical Care & Cost Containment Committee
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Eight Voting Members
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Review cases involving medical
cost disputes
Drug-Free Workplace Program
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Promote drug-free workplaces in
Tennessee
Discourage alcohol and drug abuse
Advantages
Observations
Fraud
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Employee fraud is referred to the District
Attorney General
Employer fraud is referred first to the
Uninsured Employer Fund then to the
District Attorney General
Insurer fraud is referred first to the
Department of Commerce & Insurance
then to the District Attorney General
Fraud Hotline: 1-888-243-7283
Contact Information
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Toll-free number: 1-800-332-2667
Website: www.state.tn.us/labor-wfd/wcomp
Coverage & Uninsured Employers Fund (UEF)
[email protected]
Claim Forms Filing and Electronic Data
Interchange
[email protected]
Benefit Review
[email protected]
Medical Case Management & Utilization Review
[email protected]
Drug-Free Workplace Program
[email protected]