Presumptive/Standardized Prior Approval

BWC established a program giving providers presumptive authorization to provide specific medical services without waiting for prior authorization

BWC established a program giving providers presumptive authorization to provide specific medical services without waiting for prior authorization from the managed care organization (MCO). For a period not to exceed 60 days after the date of injury, physicians have presumptive authorization to provide specific medical services without waiting for prior authorization from the MCO.

For a period not to exceed 60 days after the date of injury, physicians have presumptive authorization to provide the following services when treating soft tissue and musculoskeletal injuries that are allowed conditions in claims:

• A maximum of 12 physical medicine visits per injured worker claim which may include any combination of osteopathic manipulative treatment, chiropractic manipulative treatment, and physical medicine and rehabilitation services performed by a provider whose scope of practice includes these procedures, including, but not limited to, doctor of chiropractic, doctor of osteopathic medicine (DO), doctor of allopathic medicine (MD), physical therapist, occupational therapist, athletic trainer or massage therapist;
• Diagnostic studies, including X-rays, CAT scans, MRI scans and EMG/NCV. Note: Medical necessity for the allowed conditions is always the driver for services. Surgical diagnostics, such as arthroscopic procedures, are not included unless it is an emergency. (MCO case managers may advise providers when they identify procedures that do not appear to be medically necessary but as long as a provider follows commonly accepted treatment guidelines when treating allowed conditions in a claim, the bill will be paid);
• Fracture care recasting/splinting procedures – as medically necessary;
• Up to three soft tissue or joint injections involving the joints of the extremities (shoulder including acromioclavicular, elbow, wrist, finger, hip, knee, ankle and foot including toes) and up to three trigger point injections. Note: Injections of the paraspinal region, including epidural injections, facet injections, and sacroiliac injections are not included in the presumptive approval guidelines; and
• Consultation services.

All of the following are completed prior to initiating treatment noted above:

• The First Report of Injury (FROI) is filed with the MCO;
• The Physician’s Request for Medical Service or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease (C-9) is filed with the MCO. The MCO will notify the provider within three business days acknowledging receipt of the C-9 and that a review was completed to ensure services being rendered are medically necessary for the claim allowance. When the claim or condition for which treatment is being requested is not yet in an allowed status, the MCO may use disclaimer language notifying the provider that service will not be paid if the claim is not allowed; and
• The MCO is notified within 24 hours of treatment if the injured worker will be off work for more than two calendar days.

Resources

• Standardized Prior Authorization Table