Section 0800-02-17-.01 - PURPOSE AND SCOPE(1) Purpose: Pursuant to Tenn. Code Ann. § 50-6-204, this chapter, together with the Medical Fee Schedule Rules, Chapter 0800-02-18-.01 et seq., and the Inpatient Hospital Fee Schedule Rules, Chapter 0800-02-19-.01 et seq., (collectively hereinafter "Rules") are hereby adopted by the Administrator in order to establish a comprehensive medical fee schedule and a related system which includes, but is not limited to, procedures for review of bills, enforcement procedures and appeal hearings. The Administrator promulgates these Rules to establish the maximum allowable fees for health care services falling within the purview of the Tennessee Workers' Compensation Law ("Law"). This chapter shall be used in conjunction with the Medical Fee Schedule Rules (Chapter 0800-02-18) and the Inpatient Hospital Fee Schedule Rules (Chapter 0800-02-19). The Rules establish maximum allowable fees and procedures for all medical care and services provided to any employee claiming medical benefits under the Tennessee Workers' Compensation Law. Employers and providers may negotiate and contract or pay lesser fees as are agreeable between them, but in no event shall reimbursement be in excess of the Rules, subject to the civil penalties prescribed in the Rules, as assessed by, and in the discretion of, the Administrator, the Administrator's designee, or an agency member appointed by the Administrator. These Rules are applicable only to those injured employees claiming benefits under the Tennessee Workers' Compensation Law.
(2) Scope: These rules do the following:(a) Establish procedures by which the employer shall furnish, or cause to be furnished to an employee who sustains a personal injury, illness, or occupational disease, reasonable and necessary medical, surgical, hospital services and medicines, or other attendance or treatment recognized by the laws of the state as legal.(b) Establish schedules of maximum fees by a health facility or health care provider for such treatment or attendance, service, device, apparatus, or medicine.(c) Establish procedures by which a health care provider shall be paid the lesser of: (1) the provider's usual bill,(2) the maximum fee established under these Rules, or(3) the MCO/PPO or any other negotiated and contracted or lower price, where applicable, unless a waiver is granted by the administrator.(d) Identify utilization of health care and health services which is above the usual range of utilization for such services, based on medically accepted standards.(e) Permit review by the Bureau of the records and medical bills of any health facility or health care provider to determine if they are in compliance with these Rules.(f) Provide for deposition and witness fees.(g) Establish maximum fees for medical reports.(h) Provide for uniformity of billing for provider services.(i) Establish the effective date for implementation of these Rules. Adopt by reference as part of these Rules the International Classification of Diseases, ICD-9-CM and ICD-10-CM, the American Medical Association's Current Procedural Terminology (CPT®) and Center for Medicare and Medicaid Services (CMS-Medicare) guidelines, Medical Fee Schedule Rules (Chapter 0800-02-18), the Inpatient Hospital Fee Schedule (Chapter 0800-02-19) and any amendments to them.(j) Establish procedures for reporting of medical claims.(k) Establish procedures for pre-authorization for payments of non-emergency hospitalizations, transfers between facilities, and outpatient services.(l) Establish procedures for imposing and collecting civil penalties for violations of these Rules.(m) These rules shall apply where appropriate in conjunction with electronic submission of payments (electronic billing). See Rule 0800-02-26.Tenn. Comp. R. & Regs. 0800-02-17-.01
Public necessity rule filed June 5, 2005; effective through November 27, 2005. Public necessity rule filed November 16, 2005; effective through April 30, 2006. Original rule filed February 3, 2006; effective April 19, 2006. Amendments filed June 12, 2009; effective August 26, 2009. Amendment filed December 26, 2013; effective March 26, 2014. Repeal and new rules filed November 27, 2017; effective February 25, 2018. Amendments filed June 12, 2019; effective September 10, 2019. Administrative changes made to this chapter on September 10, 2019; "Tennessee Workers' Compensation Act" or "Act" references were changed to "Tennessee Workers' Compensation Law" or "Law." Amendments filed June 28, 2021; effective September 26, 2021. Amendments filed June 27, 2023; effective 9/25/2023.Authority: T.C.A. §§ 50-6-102, 50-6-118, 50-6-125, 50-6-128, 50-6-202, 50-6-204, 50-6-205, 50-6-226, and 50-6-233 (Repl. 2005) and Public Chapters 282 & 289 (2013).