Whats Going On At The Workers Compensation Division.

What’s Going On At The Workers’ Compensation Division

Our Mission

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

Court administered Regulatory and administrative

responsibilities divided– Department of Commerce and

Insurance– Department of Labor and Workforce

Development Workers’ Compensation law is a

compromise between employer and employee

Claims

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

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 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

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)

Detailed information available by emailing a request to [email protected]

Employer Requirements

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

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

Investigates and penalizes employers who fail to have workers’ compensation coverage

Goals Penalty Process Injunction

Benefit Review

Purpose

– To resolve disputes– To minimize adversarial relationships– Decrease litigation– Reduce overall costs of claims

Benefit Review

Staff

– Workers’ Compensation Representatives – Workers’ Compensation Specialists– Administrative Support Staff

Locations (Six area offices):– Nashville– Memphis– Jackson– Knoxville– Chattanooga– Kingsport

Benefit Review

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

Workers’ Compensation Specialist Functions

– Temporary Disability & Medical Treatment Issues

– Mediation of Permanent Disability Issues

– Approval of Settlements

Benefit Review

Request for Assistance

– Statute of Limitations is Tolled– Handled in area where employee lives– Establishes a State File Number

Medical Case Management

Definition Thresholds Qualifications Elements

Utilization Review

Provisions Requirements

Permanent Total Disability

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

Eight Voting Members

Review cases involving medical cost disputes

Drug-Free Workplace Program

Promote drug-free workplaces in Tennessee

Discourage alcohol and drug abuse Advantages Observations

Fraud

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 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 [email protected]

Drug-Free Workplace [email protected]

Whats Going On At The Workers Compensation Division.

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