Section 0800-02-07-.04 - ELEMENTS OF CASE MANAGEMENT(1) Case management services shall include, but not be limited to, the following elements required in T.C.A. § 50-6-123 [Section 7(b) of Public Chapter 900]:(a) Developing a treatment plan to provide appropriate medical services to an injured or disabled employee;(b) Systematically monitoring the treatment rendered and the medical progress of the injured or disabled employee;(c) Assessing whether alternate medical care services are appropriate and delivered in a cost-effective manner based on acceptable medical standards;(d) Ensuring that the injured or disabled employee is following the prescribed medical care plan; and(e) Formulating a plan for return to work with due regard for the employee's recovery and restrictions and limitations, if any.(2) A case manager shall not: (a) Prepare the panel of physicians or influence the employee's choice of physician;(b) Determine whether the case is work related;(c) Question the physician or employee regarding issues of compensability;(d) Conduct or assist any party in claims negotiation, investigation, or any other non-rehabilitative activity;(e) Advise the employee as to any legal matter including settlement options or procedures, monetary recovery, claims evaluation, or the applicability of the workers' compensation act to the employee's claim;(f) Accept any compensation or reward from any source as the result of settlement;(g) Discuss with the employee or physician what the impairment rating should be;(h) Reschedule medical appointments without first discussing the scheduling change with the employee;(i) Refuse to provide case management reports to parties to the claim;(j) Assist in any way in recording the employee's activity for the purposes of disproving the employee's claim; or(k) Deny or authorize treatment for the purpose of guaranteeing prepayment or precertification. (3) Any case manager that commits any of the actions provided in paragraph (2) may be assessed a civil penalty of up to five hundred dollars ($500) for each action committed. The Administrator shall have discretion to suspend the registration of any case manager assessed more than three (3) penalties in any two (2) year period for up to sixty (60) days. The Administrator shall have discretion to suspend the registration of any case manager for up to one (1) year for offenses after the three-penalty limit within any two (2) year period. Any case manager suspended by the Administrator pursuant to this paragraph shall not provide case management services to any employee receiving treatment for a workers' compensation injury during the period of suspension. Any case manager who has had their registration suspended by the Administrator who provides case management services during the period of suspension shall be assessed a civil penalty of one thousand dollars ($1,000) and shall have their registration suspended for six (6) months.(4) Failure to submit the required forms within thirty (30) days of referral and within thirty (30) days of closing the case may result in a civil penalty of one hundred dollars ($100) per occurrence.(5) It is the intent of the case management system to expedite communication and provide a conduit for improving the efficiency and timeliness of care in all cases where case management is undertaken. To that end, all providers, injured workers, adjusters and employers should utilize case management to its fullest extent and provide expedited responses to the case manager's requests.Tenn. Comp. R. & Regs. 0800-02-07-.04
Original rule filed January 28, 1993; effective May 13, 1993. Amendment filed March 20, 2007; effective July 27, 2007. Amendment filed December 26, 2013; effective March 26, 2014. Repeal and new rule filed May 31, 2016; effective 8/29/2016.Authority: T.C.A. §§ 4-5-202, 4-5-301, 50-6-102, 50-6-118, 50-6-122, 50-6-123, 50-6-126, 50-6-233, Public Acts 1992, Chapter 900, § 7, and Public Acts 2013, Chapters 282 and 289.