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Whats Going On At The Workers Compensation Division.

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Presentation on theme: "Whats Going On At The Workers Compensation Division."— Presentation transcript:

1 Whats Going On At The Workers Compensation Division

2 Our Mission n To promote the benefits and responsibilities of the Workers Compensation Act n To make available the services provided by the Act n To act in a manner that is fair, consistent, professional, and impartial to everyone

3 Profile of WC in Tennessee n Court administered n Regulatory and administrative responsibilities divided –Department of Commerce and Insurance –Department of Labor and Workforce Development n Workers Compensation law is a compromise between employer and employee

4 Claims n 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

5 Claims, continued n Employees required by Law –To report injury to employer within 30 days –Select an authorized treating physician –Follow medical providers instructions –Cooperate with all parties

6 EDI n Electronic Data Interchange (EDI) n 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.

7 EDI, continued n 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) n Detailed information available by ing a request to

8 Employer Requirements n 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 n Some employers and employees are not covered by the Law n State and local governments are exempt from the Law

9 Coverage n Every employer subject to law is required to provide coverage n Three types of coverage n Every employer required to provide proof of coverage n Every employer required to display Tennessee Workers Compensation Insurance Notice

10 Uninsured Employer Fund n Investigates and penalizes employers who fail to have workers compensation coverage n Goals n Penalty Process n Injunction

11 Benefit Review n Purpose –To resolve disputes –To minimize adversarial relationships –Decrease litigation –Reduce overall costs of claims

12 Benefit Review n Staff –Workers Compensation Representatives –Workers Compensation Specialists –Administrative Support Staff n Locations (Six area offices): –Nashville –Memphis –Jackson –Knoxville –Chattanooga –Kingsport

13 Benefit Review n Workers Compensation Representative Functions –Toll-free number: –General Information about workers compensation –Initial Dispute resolution –Send Request for Assistance

14 Benefit Review n Workers Compensation Specialist Functions –Temporary Disability & Medical Treatment Issues –Mediation of Permanent Disability Issues –Approval of Settlements

15 Benefit Review n Request for Assistance –Statute of Limitations is Tolled –Handled in area where employee lives –Establishes a State File Number

16 Medical Case Management n Definition n Thresholds n Qualifications n Elements

17 Utilization Review n Provisions n Requirements

18 Permanent Total Disability n 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. n Each year an employee who is receiving permanent total disability benefits is required to certify that he/she continues to be permanently totally disabled

19 Medical Care & Cost Containment Committee n Eight Voting Members n Review cases involving medical cost disputes

20 Drug-Free Workplace Program n Promote drug-free workplaces in Tennessee n Discourage alcohol and drug abuse n Advantages n Observations

21 Fraud n Employee fraud is referred to the District Attorney General n Employer fraud is referred first to the Uninsured Employer Fund then to the District Attorney General n Insurer fraud is referred first to the Department of Commerce & Insurance then to the District Attorney General n Fraud Hotline:

22 Contact Information n Toll-free number: n Website: n Coverage & Uninsured Employers Fund (UEF) n Claim Forms Filing and Electronic Data Interchange n Benefit Review n Medical Case Management & Utilization Review n Drug-Free Workplace Program


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