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You are here: Home . wc . news . advisories . ad2002-02

Advisory 2002-02

Carrier Failure to Timely Respond to a Request for Preauthorization, Concurrent Review OR Reconsideration is Considered a Denial and also Subjects the Carrier to Enforcement Action

This Advisory addresses the situation in which a carrier fails to timely respond to a request for preauthorization, concurrent review or reconsideration (request) and replaces Advisory 96-11, originally issued on June 28, 1996.

TWCC Rule 134.600(f)(3) requires carriers to"contact the requestor or employee by telephone, facsimile, or electronic transmission with the decision to approve or deny the request: (A) within three working days of receipt of a request for preauthorization; or (B) within three working days of receipt of a request for concurrent review, except for health care listed in subsection (i)(1), which is due within one working day of the receipt of the request."

TWCC Rule 134.600(g)(2) provides that in the event of a denial, reconsideration of the denial may be requested and that the carrier is required to "respond to the request for reconsideration of the denial: (A) within five working days of receipt of a request for reconsideration of denied preauthorization; or (B) within three working days of receipt of a request for reconsideration of denied concurrent review, except for health care listed in subsection (i)(1), which is due within one working day of the receipt of the request."

As was the case in 1996, if a carrier fails to respond to a request (either initial or reconsideration), such failure to timely respond is an administrative violation pursuant to §415.0035(a)(3), (c) and/or (e). A repeat of the violation by a carrier can result in the issuance of an administrative penalty under §415.021 not to exceed $10,000.00. However, enforcement action does not solve the immediate problem: that of securing an approval or denial of the request so the employee can receive the health care or the matter can proceed to the next step, requesting reconsideration or Medical Dispute Resolution.

As in Advisory 96-11, the Commission considers the carrier's failure to respond to a request to be a de facto denial of the request, which is made in a manner that is not in accordance with Commission rules. In the denial of an initial request (by failure to respond), a request for reconsideration may be filed; in the denial of a request for reconsideration (by failure to respond), a request for Medical Dispute Resolution (MDR) may be filed. Pursuant to §133.308(f)(3), a request for MDR must include "documentation of the request for and response to reconsideration, or, if the respondent failed to respond to a request for reconsideration, convincing evidence of carrier receipt of that request." Since a dispute regarding a denied request for reconsideration of preauthorization or concurrent review is a Prospective Necessity Dispute, the medical necessity is reviewed by an Independent Review Organization (IRO) at the expense of the carrier.

Signed this 29 th day of January, 2002

Richard F. Reynolds, Executive Director

Distribution:
TWCC Staff
Medical Professional Associations
Carrier Representatives
Forms Notification List
Public Information List
TWCC web site



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