Section 0800-02-25-.02 - DEFINITIONS(1) "Act" means the applicable Workers' Compensation Law in effect.(2) "Administrator" means the chief administrative officer of the Tennessee Bureau of Workers' Compensation, or the Administrator's designee.(3) "Authorized Treating Physician" means the practitioner chosen from the panel required by T.C.A. § 50-6-204, or a practitioner who has received a referral from the original authorized treating physician if the employer has not provided an alternative referral within three business days. "Authorized Treating Physician" also means any practitioner specifically authorized by the employer.(4) "Bureau" means the Tennessee Bureau of Workers' Compensation attached for administrative purposes to the Tennessee Department of Labor and Workforce Development.(5) "Employee" means an employee as defined in T.C.A. § 50-6-102, but also includes the employee's representative or legal counsel.(6) "Employer" means an employer as defined in T.C.A. § 50-6-102, but also includes an employer's insurer, third party administrator, self-insured employers, self-insured pools and trusts, as well as the employer's representative or legal counsel, as applicable.(7) "Health care provider" includes, but is not limited to, the following: licensed individual chiropractic physician, dentist, physical therapist, physician, physician assistant, optometric physician, podiatrist, surgeon, occupational therapist, group of practitioners, hospital, free standing surgical outpatient facility, health maintenance organization, industrial or other clinic, occupational healthcare center, home health agency, visiting nursing association, laboratory, medical supply company, community mental health center, pharmacist/pharmacy, and any other facility or entity providing treatment or health care services for a work-related injury.(8) "Medical Director" means the Medical Director of the Tennessee Bureau of Workers' Compensation appointed by the Administrator pursuant to T.C.A. § 50-6-126, or the Medical Director's designee.(9) "Medically necessary" or "medical necessity" means healthcare services, including medications, that a physician (or other healthcare provider acting within their scope of practice), exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are: (a) In accordance with generally accepted standards of medical practice; and(b) Clinically appropriate, in terms of type, frequency, extent, site and duration; and considered effective for the patient's illness, injury or disease. Treatment primarily for the convenience of the patient, physician, or other healthcare provider does not constitute medical necessity.(10) "Treatment guideline" means the Institute of Medicine (2011) definition of a "clinical practice guideline": "statements that include recommendations intended to optimize patient care that are informed by a systematic review of the evidence and an assessment of the benefit and harms of alternative care options."(11) "Utilization review" means evaluation of the necessity, appropriateness, efficiency and quality of medical care services, including the prescribing of one (1) or more Schedule II, III, or IV controlled substances for pain management for a period of time exceeding ninety (90) days from the initial prescription of such controlled substances, provided to an injured or disabled employee based on medically accepted standards and an objective evaluation of those services provided; provided, that "utilization review" does not include the establishment of approved payment levels, a review of medical charges or fees, or an initial evaluation of an injured or disabled employee by a physician specializing in pain management;(a) "Utilization review" does not include elective requests for clarification of coverage, referrals, consultations, second opinions from medical providers, or office visits.(b) "Utilization review" does not include analysis of or opinions regarding medical causation or compensability.Tenn. Comp. R. & Regs. 0800-02-25-.02
Original rule filed November 30, 2015; effective 2/28/2016.Authority: T.C.A. §§ 50-6-102, 50-6-122, 50-6-124, 50-6-126, 50-6-233, 56-6-703, and 56-61-102.