BWC requires prior authorization for non-emergency treatment and services by submitting a Request for Medical Service Reimbursement or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease (C-9) or its equivalent, to the managed care organization (MCO).
“Emergency” services are “Medical services that are required for the immediate diagnosis and treatment of a condition that, if not immediately diagnosed and treated, could lead to serious physical or mental disability or death, or that are immediately necessary to alleviate severe pain. Emergency treatment includes treatment delivered in response to symptoms that may or may not represent an actual emergency, but is necessary to determine whether an emergency exists.”
The Standardized Prior Authorization Table details the prior authorization requirements. The table does not include items meeting the presumptive approval criteria.
To help the MCO consider authorization and improve the bill payment process, BWC has the following guidelines:
- The physician of record or treating physician submits the treatment authorization request to the appropriate MCO before initiating any non-emergency treatment. The preferred method of submission is the;
- The MCO must provide a decision to the physician within three business days. The MCOs must fax the authorized, denied or pending treatment request. If they cannot fax their decision, they must call the physician and then follow up by mail;
- If the MCO is unable to make a decision within three business days, because of a need for additional information and the physician is notified, the MCO will send a Request for Additional Medical Documentation (C-9-A) to the physician. MCOs have five business days from the date they receive the additional information to make a subsequent decision. The MCO may deny the treatment request if the physician does not provide any requested documentation within five business days as required by the provider agreement. The MCO must notify the physician of the subsequent decision by fax or telephone and follow up by mail. If the MCO is unable to make a decision within three business days because of a need for a medical review, the MCO must notify the physician. The medical review must take place and a decision made within five days. Again, the MCO must notify the physician of the subsequent decision by fax or telephone and follow up by mail;
- A provider may initiate treatments when all of these criteria are met:
- The MCO fails to communicate a decision to the physician within three business days of receiving the original treatment request or within five business days if the request is pending;
- The physician documented the treatment request completely and correctly on a C-9 or other acceptable document;
- The physician has proof of submission to the appropriate MCO;
- Treatment is for the allowed conditions;
- The claim is in a payable status.
- The MCO will authorize, deny or pend a provider’s proposed retroactive treatment request within 30 calendar days from receipt;
- Self-insuring employers must approve or deny treatment plans within 10 days.
In instances where the MCO does not respond to the C-9 within three days and the provider initiates treatment, the MCO will provide a concurrent and retro review. If the MCO decides the treatment is not necessary, the MCO will notify all parties that treatment should be discontinued. And the MCO will pay for services rendered up to that point.