Magnifying Glass
Back to Workers' Compensation Daily Headlines

Glossary Check: Tenn. 'Utilization Review'

01 Feb, 2023 Frank Ferreri

                               

Nashville, TN (WorkersCompensation.com) -- The utilization review process is a part of the workers' compensation system in most states that makes determinations about an injured worker's ongoing medical treatment.

One of those states is Tennessee, which, not surprisingly, defines the process and aspects of it via state workers' compensation law. Here's a look at those definitions from the Volunteer State.

Utilization Review

  • A system for prospective and concurrent review of the necessity and appropriateness in the allocation of health care resources and services given or proposed to be given to an individual.
  • “Utilization review” does not include elective requests for clarification of coverage.

Utilization Review Agent

  • Any person or entity, including the state, performing utilization review, except:
    • An agency of the federal government.
    • An agent acting on behalf of the federal government, but only to the extent that the agent is providing services to the federal government.
    • A hospital's internal quality assurance program.
    • An employee of a utilization review agent.
    • Health maintenance organizations licensed and regulated by the commissioner, but only to the extent of providing utilization review to their own members.
Notable Case
 
In Walker v. G. UB. MK Constructors, 2016 WL 2343177 (Tenn. 05/02/16), Tennessee's Supreme Court explained that an affidavit of a non-treating doctor from the utilization review process, which found that a worker's treatment was not medically reasonable or necessary, was sufficient to rebut the presumptin that the treatments ordered by the treating doctor were necessary.
 
Why?
  • In the utilization review process, the non-treating doctor reviewed "the pertinent medical records and reports."
  • Each doctor in the utilization review process concluded that trigger point injections, percutaneous neuromodulcation therapy, and aquatic thereapy were not medically reasonablly or necessary.

Find compliance information from Tennessee and the rest of the U.S. on WorkCompResearch

  • california case management case management focus claims compensability compliance compliance corner courts covid do you know the rule exclusive remedy florida glossary check Healthcare health care hr homeroom insurance insurers iowa kentucky leadership medical NCCI new jersey new york ohio opioids osha pennsylvania Safety simply research state info technology texas violence WDYT west virginia what do you think women's history month workcompcollege workers' comp 101 workers' recovery workers' compensation contact information Workplace Safety Workplace Violence

    • Read Also

    Building a Return-to-Work Culture Before an Injury Occurs: Setting the Stage for Success 

    In workers’ compensation, the return-to-work (RTW) process is often viewed as a reactive step—something that begins after an injury occurs. However, organizations that prioritize return-to-work culture before an injury occurs set the stage for smoother […]
    Was Curling Lawnmowers with Shoulder Injury Xmas Miracle or Misrepresentation?

    What Do You Think? Schenectady, NY (WorkersCompensation.com) -- A few key pieces of evidence usually work together to show whether an employee was or was not misrepresenting his injuries to obtain workers’ compensation benefits. In […]
    Our Favorite 12 Stories of 2024

    Stuart, FL (WorkersCompensation.com) -- It's that time of year again where the news desk looks back on what we learned that we might be able to take forward for a better new year. Or maybe […]

    About The Author

    • Frank Ferreri

      Frank Ferreri, M.A., J.D. covers workers' compensation legal issues. He has published books, articles, and other material on multiple areas of employment, insurance, and disability law. Frank received his master's degree from the University of South Florida and juris doctor from the University of Florida Levin College of Law. Frank encourages everyone to consider helping out the Kind Souls Foundation and Kids' Chance of America.

    More by This Author

    Our Favorite 12 Stories of 2024

    Stuart, FL (WorkersCompensation.com) -- It's that time of year again where the news desk looks back on what we learned that we might be able to take forward for a better new year. Or maybe […]
    California Round-Up

    California content on WorkersCompensation.com is brought to you by Quiescence Congregate Living Health Facility. What are Workers’ Compensation ‘Benefits’ in California? (12/18/24)What you'll learn: Definitions of terms pertinent to benefits available to workers in California under […]
    What are Workers’ Compensation ‘Benefits’ in California?

    Glossary Check If someone was talking about "benefits" in California, would you know what they are? The Golden State spells them out on the state-required Notice to Employees poster, which Simply Research subscribers have access […]

    Read More

    Building a Return-to-Work Culture Before an Injury Occurs: Setting the Stage for Success 

    In workers’ compensation, the return-to-work (RTW) process is often viewed as a reactive step—something that begins after an injury occurs. However, organizations that prioritize return-to-work culture before an injury occurs set the stage for smoother […]
    Was Curling Lawnmowers with Shoulder Injury Xmas Miracle or Misrepresentation?

    What Do You Think? Schenectady, NY (WorkersCompensation.com) -- A few key pieces of evidence usually work together to show whether an employee was or was not misrepresenting his injuries to obtain workers’ compensation benefits. In […]
    Our Favorite 12 Stories of 2024

    Stuart, FL (WorkersCompensation.com) -- It's that time of year again where the news desk looks back on what we learned that we might be able to take forward for a better new year. Or maybe […]
    Ergonomics and Workplace Modifications: Reducing Strain and Preventing Injuries 

    Ergonomics and workplace modifications are essential components of a proactive workers’ compensation program. An ergonomically sound workplace reduces physical strain on employees, minimizes the risk of injury, and fosters a healthier, more productive workforce. For […]
    Air Industry Facing Continued Threats as Peak Holiday Travel Period Arrives

    Houston, TX (WorkersCompensation.com) – Airlines and air industry employees continue to face threats as the busiest periods of the holiday travel season nears. Since 2021, the airline industry has seen a rash of threatening and/or […]
    Developing an Injury Prevention Plan: A Strategic Approach to Workplace Safety 

    Preventing injuries is the ultimate goal of workers' compensation. While accidents may seem inevitable, a proactive injury prevention plan can significantly reduce risks, protect employees, and enhance organizational efficiency. This fourth article in the Workers’ […]