Reporting a Claim
If your employee gets hurt at work or gets sick from his/her job, the Tennessee’s Workers’ Compensation Act requires most employers to pay for the medical treatment needed. Employees do not have to pay to get workers’ compensation benefits. It does not generally matter whether the accident was the employee’s fault, another worker’s, or the employer’s; employees still get the benefits spelled out in Tennessee’s Workers’ Compensation law. Most employers and insurance adjusters provide benefits without assistance from the Bureau. If you are not having problems with your claim, you do not need to contact us. View our Beginner’s Guide to Tennessee Workers’ Compensation.
How to Handle the Report of Claim
Tennessee has strict claims handling standards for adjusters and employers to ensure that work-related injuries and illnesses are reported timely and correctly. Employers covered by the Tennessee Workers’ Compensation Act must submit all known or reported injuries or illnesses to their insurance carriers, unless they are qualified to be a self-insured employer, within one (1) working day of the employer’s knowledge of the injury or illness.
Reportable workplace injuries or illnesses are those that cause:
- An employee to receive medical treatment outside of the employer’s premises
- Their death
- Their absence from work, or their retention of a permanent impairment
Decisions on workers’ compensation insurance coverage and compensability must be made within fifteen (15) days of a verbal or written notice of an accident or injury. The employer should work with its adjuster in making this determination. Upon making its decision after a proper investigation adjuster must file, with the Division, the appropriate forms. Claimants and employers must be notified of the decision of compensability within fifteen (15) days of the notice.
- If an adjuster accepts the claim, and indemnity benefits are paid, a Notice of First Payment of Compensation (Form C-22)must be filed immediately. Employers, self-insured employers, and/or insurance companies shall file Form C-22 through EDI.
- Immediately upon the change or termination of benefits, adjusters must file Notice of Change or Termination of Compensation Benefits (Form C-26) through EDI.
- If an adjuster denies a claim, a Notice of Denial of Claim For Compensation Form (Form C-23) must be filed with the Division on both paper and through EDI and a copy of that form must be provided to the claimant at the same time. The adjuster must provide documentation which meets the statutory criteria for denial on that form. The denial of a claim must also be supported with documented results of an investigation.
- A Notice of Controversy (Form C-27) shall be filed in claims only if temporary disability payments have already been started and the employer or adjuster subsequently elects to controvert its liability.
Know Your Rights
Employers have the right to expect a report of an injury or illness that an employee suspects is caused by work to be reported without delay. Employers have the right to restrict their employees’ choice of physicians by providing a panel of physicians as described below.
Employers have the right to help reduce the cost of medical treatment by negotiating the medical fees with the providers on their panels. Tennessee’s Medical Fee Schedule doesn’t mandate the cost of treatment; rather, it creates a “ceiling” for those costs but allows parties to negotiate lesser rates. Learn more about the Medical Fee Schedule.
Report the Injury to your Insurance Provider
Employers covered by the Tennessee Workers’ Compensation Act must immediately submit all known or reported injuries or illnesses to their insurance carriers unless the employer is qualified and certified as a self-insured employer. Employers qualified and certified as self-insured employers should submit all reported injuries or illnesses to their third party administrator or internal claims handling program. Reportable workplace injuries or illnesses are those that cause
- An employee to receive medical treatment outside of the employer’s premises;
- Their absence from work; or,
- Their death.
Employers should report all injuries to their insurance carrier or Third Party Administrator. Employers should not pay for treatment without reporting the injury.
Injuries that meet the standards above, even if they do not involve lost time, must be reported to the carrier or Third Party Administrator.
Medical Care and Paperwork
After an employee reports an injury, employers should help the employee get all needed medical care related to the injury, at no cost to the employee, from a doctor the employee chooses from the employer’s approved list. Employers should also help the employee contact the employer’s Workers’ Compensation insurance adjuster.
- Fill out a First Report of Injury (Form C-20) and file the form with its insurance adjuster within one (1) working day of its knowledge of the injury. The claim must be reported to the adjuster even if the employer feels the claim is not work-related. Self-insured employers must either report the claim to their Third Party Administrator (TPA) or internal claims handling program. Employers should not pay for medical benefits or disability benefits from a “petty cash” fund without reporting the claim.
- Provide the injured employee a timely and valid panel of physicians, within the community of the injured employee’s home or workplace, on an Agreement Between Employer/Employee Choice of Physician Form (Form C-42). If the employer does not have a valid panel of physicians available at the time the injury is reported, it should immediately call its insurer and develop one. Alternative versions of the form are not allowed.
- Have the employee select a physician from the panel and sign the form. This selected physician becomes the “authorized treating physician.” The employer should keep the original signed form and provide a copy to the employee.
- Assist the employee and/or the insurance adjuster in scheduling the initial appointment and in authorizing medical treatment.
- Employees injured prior to July 1, 2014 must also sign a Medical Waiver and Consent Form (Form C-31). This form allows the employer, or its representatives, to communicate with the treating physician about the treatment for the injury. The form is optional for injuries after that date.
- Submit a statement of the employee's wages to their workers’ compensation insurance adjuster on a Wage Statement (Form C-41). The wage statement should show the gross wages earned by the injured employee, including overtime, bonuses, etc., each week for the fifty-two (52) weeks prior to the injury. Alternative versions of the form are not allowed.
Payment of Wage Replacement Benefits
Wage replacement benefits for compensable claims are paid by the insurance provider, not by the Bureau. Temporary disability payments for work missed due to a compensable work-related injury or illness must be received by the injured employee no later than 15 calendar days after the notice of injury. Unpaid or untimely paid benefits may be subject to a penalty.
Other Employer Requirements
Need More Help?
If you have additional questions, please call 615-532-4812 or 800-332-2667 or contact us by email at firstname.lastname@example.org.