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CHAPTER 0800-02-07
GENERAL RULES OF THE WORKERS’ COMPENSATION PROGRAM CASE MANAGEMENT 

 

0800-02-07-.02 CASE MANAGEMENT SYSTEM. 

• (1)  An insurer who provides workers’ compensation insurance regulated by the provisions of T.C.A., Title 50, Chapter 6 or a self-insured employer may provide for a system of case management for cases involving compensable injuries under T.C.A., Title 50, Chapter 6. 

  • (a)  Any insurer providing workers’ compensation insurance under T.C.A., Title 50, Chapter 6, may provide for or contract for case management services when such services are provided.

  • (b)  The insured employer may choose to provide case management services itself or through a third party administrator. If so, the insured employer shall inform its insurer in writing of its choice.

 

0800-02-07-.03 CASE MANAGEMENT THRESHOLD. 

• (1)  Catastrophic Injuries. An employer or insurer should provide case management services in all cases where an employee has suffered a catastrophic injury. The employer or insured should assign a case manager within seven (7) calendar days of receiving notice that the employee has suffered a catastrophic injury. There shall be one face-to-face meeting within fourteen calendar days after the assignment. After the initial meeting, there should be face-to-face meetings or other communications as necessary for the progress of the patient until such time as case management services are concluded. Should an employee experience a significant decline in their medical condition, there should be a face-to-face meeting between the case manager and the employee within fourteen (14) calendar days of notification of such a change. Documentation evidencing the first face-to-face meetings shall be submitted to the Medical Director of the Tennessee Bureau of Workers’ Compensation within thirty (30) calendar days of the first meeting on the Bureau’s required case management form.

• (2)  Non-catastrophic Injuries. For non-catastrophic injuries, there should be one initial face-to- face meeting if and when a case manager is assigned to the claim. This should occur within 14 days of the assignment. It is appropriate to consider case management services if medical expenses over $10,000 (ten thousand dollars), an impatient hospitalization, or lost work time over three months is anticipated. Further meetings and communication should occur as the case warrants. Documentation evidencing the initial face-to-face meetings shall be submitted to the Medical Director of the Tennessee Bureau of Workers’ Compensation within thirty (30) calendar days, if medical expenses over $10,000 (ten thousand dollars), an impatient hospitalization, or lost work time over three months is anticipated, on the Bureau’s required case management form.

 

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.