Tenn. Comp. R. & Regs. 0800-02-27-.10

Current through January 8, 2025

Section 0800-02-27-.10 - REQUIRED TRAINING PROGRAM FOR CERTIFIED ADJUSTING ENTITIES

(1) Prior to being recognized as a certified adjusting entity by the Bureau, an adjusting entity shall establish and implement a training program for adjusters that process Tennessee claims and shall provide:

(a) Newly-hired medical-only adjusters with at least eight (8) hours of claims-related training;

(b) Newly-hired or newly-appointed claims adjusters with at least twelve (12) hours of claims-related training;

(c) Medical-only and claims adjusters, who are not newly-hired or newly-appointed, with at least two (2) hours of Tennessee-specific training each year; and

(d) Supervising Adjusters who are not newly-hired or newly-appointed with at least four (4) hours of Tennessee-specific claims processing training each year.

(2) All required training for new hires or newly-appointed adjusters shall be provided within the first thirty (30) calendar days of the date or hire or appointment to the position and shall include:

(a) Overview of the information contained on the Tennessee Bureau of Workers' Compensation's Internet homepage

(b) Overview of the Tennessee Workers' Compensation Law including:

1. Notice requirements for employers and claimants

2. Adjuster duties when an injury is reported by an employer

3. Time frame for accepting/denying claim

4. Elements of good faith

5. Claims forms filing requirements/EDI

6. Exclusive remedy

(c) Insurance principles of compensation

1. Medical evidence

2. Investigations

3. Documentation

4. Tennessee-specific Compensability Issues

(i) Course of employment/Arising out of employment

(ii) Covered injuries

(iii) Occupational diseases

5. Denying a claim

(i) Willful misconduct

(ii) Intoxication

(iii) Failure to use safety equipment

(iv) Statute of limitations

6. Fraud

(d) Medical billing codes

(e) Benefits provisions

1. Tennessee requirements for medical panels

2. Medical benefits

3. Temporary disability benefits

4. Permanent disability benefits and issues concerning impairment ratings

5. Future medical benefits

6. Death benefits

(f) Return to work and vocational rehab

(g) Cumulative trauma and gradually occurring injuries

(h) Medical terminology and abbreviations

1. Medical reports

2. Medical specialties

3. Common occupational injuries and diseases

4. Common medical tests

(i) Controlling Costs

1. Employee Choice of Physician Form C-42

2. Medical Fee Schedule

3. Case Management

4. Utilization Review

5. Treatment Guidelines and Drug Formulary

(j) Settlement negotiations

1. Mediation and Ombudsman Services of Tennessee (MOST)

2. Court of Workers' Compensation Claims

3. Workers' Compensation Appeals Board

(k) Ethical Issue

1. Elements of bad faith

2. Tennessee's Penalty statutes

(3) All required training for medical-only and claims adjusters and Supervisors, who are not newly-hired or newly-appointed, shall include information regarding industry best practices as well as any updates to the Workers' Compensation Law or to the Bureau's rules and/or programming areas.

(4) Adjusting entities recognized by this program shall be allowed to indicate its claims processing services are "Recognized by the Tennessee Bureau of Workers' Compensation as a certified adjusting entity in advertising and on its letterhead only during the time frame the adjusting entity is so recognized.

(5) The Bureau may, at its discretion, provide the names and other non-protected personal information, of any adjuster or adjusting entity that has been certified by this program on its website or in any other means it chooses.

Tenn. Comp. R. & Regs. 0800-02-27-.10

Original rule filed March 2, 2018; effective 5/31/2018.

Authority: T.C.A. §§ 50-6-101, 50-6-119, 50-6-127, 50-6-233, 50-6-415, and 50-6-419.