October 31, 2017
The State provides a workers’ compensation program to approximately 75,000 state employees in accordance with Tennessee’s general workers’ compensation laws. The mission of the State in this area is to provide prompt and high quality medical and pharmaceutical services to injured state workers in a cost effective manner. Goals of the program include: (1) rendering compensability decisions to injured state workers within 14 days of their submission of an accident report form; (2) ensuring that injured state workers throughout the state have reasonable access to and receive prompt, appropriate treatments and levels of care from the health care community during their recovery from their injury; (3) providing lost time benefits, which represent salary replacement payments, to injured state workers on a biweekly basis to minimize the financial consequences of their injury; (4) payment of permanent disability benefits; and, (5) assisting injured state workers in returning to work at the earliest point possible, consistent with their injury and treatment plan.
To meet these goals, delivery of services under the program is coordinated by staff in the Department of Treasury, Division of Claims and Risk Management (DCRM). This division coordinates services for injured workers and serves a customer driven “quality control” role to ensure that employees are appropriately served by vendors with whom DCRM contracts.
Since September 1993, workers’ compensation benefits have been delivered through a third party administrator (TPA). The TPA serves as the focal point of service delivery and is responsible for investigation of all workers’ compensation claims filed by injured workers and for making determinations as to the compensability of accidents, subject to the oversight of DCRM. Once compensability is determined, the TPA makes medical and indemnity payments on the State’s behalf in accordance with state law. There are approximately 3,500 nurse triage calls a year and 2,700 claims administered annually.
Services requested in this RFP
The State intends to secure a contract for:
· State-wide workers’ compensation Pharmacy Benefits Management (PBM) services, including point-of-sale pharmacy claims processing, a mail order program, utilization management services, cost containment processes that apply state-mandated fee schedule review services to point of sales bills, out-of-network bills, paper bills, third party bills, and bills for physician dispensed medications;
· Physician Peer Review services including Physician Peer to Peer Review, Telephonic Case Management, and Cognitive Behavioral Therapy.
· Telehealth based medical services.
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