Tenn. Comp. R. & Regs. 0800-02-06-.04 - CONTENTS OF UTILIZATION REVIEW REPORT

(1) The utilization review organization shall communicate its determination to the parties within the timeframe established in Rule 0800-02-06-.06.

(2) If a utilization review appeal is filed with the Bureau, any recommended modification in a utilization review report will be considered a denial for the purpose of evaluating the appeal by the Bureau.

(3) If the utilization review determination is a denial of a recommended treatment, then the utilization review organization shall submit a written utilization review report in conformity with the requirements of subsection (4) of this Rule. If the utilization review determination is an approval of a recommended treatment, then the utilization review organization shall submit written documentation of the determination; provided that the written documentation is not required to be a utilization review report in conformity with the requirements of subsection (4) of this Rule. A utilization review report and other written documentation may be communicated through electronic means when available and appropriate.

(4) The utilization review organization physician's determination report shall contain a list of all medical information reviewed, the assessment of those records, the basis of the determination in accordance with the Bureau's adopted Treatment Guidelines, and the name and credentials of the utilization review physician. This information shall be sent to all parties. The utilization review communication to the authorized treating physician shall separately contain the information necessary for a peer-to-peer telephonic conference, or instructions on accessing an electronic portal for secure electronic communication between the utilization review physician and the authorized treating physician. This information shall be sent to the authorized treating physician and copied to the employer as defined in these rules.

(5) The utilization review determination report shall include an attestation statement and the signature of the utilization review physician that the physician has personally reviewed the list of medical information reviewed and made the determination. It shall include the utilization review physician's Tennessee license number, board certification, information and any other appropriate credential that supports the qualification of the physician.

(6) The utilization review report shall adhere to the following requirements:

(a) The utilization review organization shall consider only the medical necessity, appropriateness, efficiency, and quality of the recommended treatment for the employee's condition. The consideration under quality may include factors such as timeliness, effectiveness, efficacy, conformity to the Bureau's adopted Treatment Guidelines, and other evidence-based treatment guidelines (including the comments and observations) approved by the Administrator. Treatment recommendations shall not be denied if they follow the Bureau's adopted Treatment Guidelines.

(b) Whenever a utilization review organization determines that the recommended treatment will be denied, the utilization review report must contain specific and detailed reasons for the denial, a listing of all the documents used to make the determination, and a record of any other communication between the utilization review physician and the requesting provider.

(c) The utilization review organization shall also include the name, address, and appropriate contact number or email address of the utilization review physician making a denial determination.

(d) All utilization review reports that deny or modify any portion of a recommended treatment, including medications, shall include an appeal form prescribed by the Bureau. The utilization review organization shall transmit a copy of the utilization review report and appeal form to the authorized treating physician, employee, and employer. Upon request, the utilization review organization shall transmit any utilization review report to the Bureau. Failure to include the appeal form in the utilization review report and transmit such to all parties may result in sanctions and/or civil penalties pursuant to Rule 0800-02-06-.10 of this Chapter.

Notes

Tenn. Comp. R. & Regs. 0800-02-06-.04

Original rule filed March 5, 1993; effective April 19, 1993. Amendment filed May 13, 1997; effective July 27, 1997. Amendment filed October 12, 2007; withdrawn December 12, 2007. Repeal and new rule filed August 14, 2009; effective November 12, 2009. Amendments filed October 31, 2016; effective January 29, 2017. Amendments filed July 1, 2022; effective 9/29/2022.

Authority: T.C.A. §§ 50-6-102, 50-6-118, 50-6-124, 50-6-126, and 50-6-233.