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Advisory 2001-03

Preauthorization Process and Access to Medical Dispute Resolution

In the process of requesting preauthorization for specific treatments and services, it is necessary to apply both Rule 134.600 and Rule 133.305.

Request for preauthorization: Per Rule 134.600: Procedure for Requesting Pre-Authorization of Specific Treatments and Services, effective April 1, 1997:

The treating doctor (TD) or treating doctor's designated representative (TDs Rep) contacts the insurance carrier (IC) or the carrier's delegated agent (URA) by either telephone or fax and requests preauthorization for a specified treatment or service that is listed in Rule 134.600(h). The request must include the information necessary to support the medical necessity for the treatment or service.

Within three working days of the receipt of the request, the IC/URA is required to respond with an approval or a denial. This period of time is three working days; it is not 72 hours. The day of receipt is excluded in the count; the third working day is included. Working days are counted from the day following the receipt, excluding weekends and holidays, per Rule 102.3, Computation of Time.

Approval: If the decision is an approval (Yes), the IC/URA must notify the TD or TDs Rep by telephone or fax. This approval establishes liability for payment of the preauthorized health care.

Within 24 hours of the approval, the IC/URA must send written approval to the TD or TDs Rep, the injured employee (IE), and the injured employee's representative (IEs Rep.) if known.

Preauthorization approval process ends here. Once the IC/URA has approved the medical necessity for a specific treatment or service, the IC may not retrospectively deny payment based on medical necessity, but may retroactively dispute the amount of reimbursement.

Upon receipt of the written approval, the health care provider (HCP) may initiate the preauthorized health care. (Note: Treatment or service should not be initiated until documentation of the approval is received.)

Denial: If the decision is a denial (No), the IC/URA must notify the TD or TDs Rep by telephone or fax.

Within 24 hours of the denial, the IC/URA must send written denial to the TD or TDs Rep, the IE, and IEs Rep, if known. The notice of denial must include documentation identifying the reasons for denial.

The denial is considered final if the TD, TDs Rep, or IE does not request reconsideration to dispute the denial.

Access to Medical Dispute Resolution: Per Rule 133.305: Medical Dispute Resolution, effective July 15, 2000:

In order to access medical dispute resolution, the TD, TDs Rep, or IE must first submit a request for reconsideration of denial to the IC/URA. The requesting party must document the request.

Within seven days of the receipt of the reconsideration request [Rule 133.305(c)], the IC/URA is required to respond with an approval or a denial. Per Rule 102.3, Computation of Time, the seven days represent seven calendar days, not working days.

Reconsideration Approval: If the IC/URA approves (Yes) the request on reconsideration, the reconsideration process ends here. This approval establishes liability for payment of the preauthorized health care, the IC may not retrospectively deny payment based on medical necessity, but may retroactively dispute the amount of reimbursement. The HCP may initiate the preauthorized health care.

Reconsideration Denial: If the IC/URA denies (No) the request on reconsideration, the IC/URA must notify the TD or TDs Rep, IE, and IE's Rep if known.

Medical Dispute Resolution Option: The TD, TDs Rep, or IE may request medical dispute resolution not later than 45 days after the reconsideration denial, per Rule 133.305(d)(5).

Signed this 22 nd day of February, 2001

Leonard W. Riley, Jr., Executive Director

Distribution: TWCC Staff
Commission Representatives
Public Information List
Professional Medical Associations



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