| (a) The following words and terms when used in this
chapter shall have the following meanings, unless the context clearly
indicates otherwise:
(1) Ambulatory surgical services: surgical services
provided in a facility that operates primarily to provide surgical
services to patients who do not require overnight hospital care.
(2) Concurrent review: a review of on-going health
care listed in subsection (q) of this section for an extension of
treatment beyond previously approved health care listed in subsection
(p) of this section.
(3) Diagnostic study: any test used to help establish
or exclude the presence of disease/injury in symptomatic individuals.
The test may help determine the diagnosis, screen for specific disease/injury,
guide the management of an established disease/injury, and formulate
a prognosis.
(4) Division exempted program: a Commission on Accreditation
of Rehabilitation Facilities (CARF) accredited work conditioning or
work hardening program that has requested and been granted an exemption
by the division from preauthorization and concurrent review requirements
except for those provided by subsections (p)(4) and (q)(2) of this
section.
(5) Final adjudication: the commissioner has issued
a final decision or order that is no longer subject to appeal by either
party.
(6) Outpatient surgical services: surgical services
provided in a freestanding surgical center or a hospital outpatient
department to patients who do not require overnight hospital care.
(7) Preauthorization: prospective approval obtained
from the insurance carrier by the requestor or injured employee prior
to providing the health care treatment or services (health care).
(8) Requestor: the health care provider or designated
representative, including office staff or a referral health care provider/health
care facility that requests preauthorization, concurrent review, or
voluntary certification.
(9) Work conditioning and work hardening: return-to-work
rehabilitation programs as defined in this chapter.
(b) When division-adopted treatment guidelines conflict
with this section, this section prevails.
(c) The insurance carrier is liable for all reasonable
and necessary medical costs relating to the health care:
(1) listed in subsection (p) or (q) of this section
only when the following situations occur:
(A) an emergency, as defined in Chapter 133 of this
title (relating to General Medical Provisions);
(B) preauthorization of any health care listed in subsection
(p) of this section that was approved prior to providing the health
care;
(C) concurrent review of any health care listed in
subsection (q) of this section that was approved prior to providing
the health care; or
(D) when ordered by the commissioner;
(2) or per subsection (r) of this section when voluntary
certification was requested and payment agreed upon prior to providing
the health care for any health care not listed in subsection (p) of
this section.
(d) The insurance carrier is not liable under subsection
(c)(1)(B) or (C) of this section if there has been a final adjudication
that the injury is not compensable or that the health care was provided
for a condition unrelated to the compensable injury.
(e) The insurance carrier shall designate accessible
direct telephone and facsimile numbers and may designate an electronic
transmission address for use by the requestor or injured employee
to request preauthorization or concurrent review during normal business
hours. The direct number shall be answered or the facsimile or electronic
transmission address responded to by the insurance carrier within
the time limits established in subsection (i) of this section.
(f) The requestor or injured employee shall request
and obtain preauthorization from the insurance carrier prior to providing
or receiving health care listed in subsection (p) of this section.
Concurrent review shall be requested prior to the conclusion of the
specific number of treatments or period of time preauthorized and
approval must be obtained prior to extending the health care listed
in subsection (q) of this section. The request for preauthorization
or concurrent review shall be sent to the insurance carrier by telephone,
facsimile, or electronic transmission and, include the:
(1) name of the injured employee;
(2) specific health care listed in subsection (p) or
(q) of this section;
(3) number of specific health care treatments and the
specific period of time requested to complete the treatments;
(4) information to substantiate the medical necessity
of the health care requested;
(5) accessible telephone and facsimile numbers and
may designate an electronic transmission address for use by the insurance
carrier;
(6) name of the requestor and requestor's professional
license number or national provider identifier, or injured employee's
name if the injured employee is requesting preauthorization;
(7) name, professional license number or national provider
identifier of the health care provider who will render the health
care if different than paragraph (6) of this subsection and if known;
(8) facility name, and the facility's national provider
identifier if the proposed health care is to be rendered in a facility;
and
(9) estimated date of proposed health care.
(g) A health care provider may submit a request for
health care to treat an injury or diagnosis that is not accepted by
the insurance carrier in accordance with Labor Code §408.0042.
(1) The request shall be in the form of a treatment
plan for a 60 day timeframe.
(2) The insurance carrier shall review requests submitted
in accordance with this subsection for both medical necessity and
relatedness.
(3) If denying the request, the insurance carrier shall
indicate whether the denial is based on medical necessity and/or unrelated
injury/diagnosis in accordance with subsection (m) of this section.
(4) The requestor or injured employee may file an extent
of injury dispute upon receipt of an insurance carrier's response
which includes a denial due to unrelated injury/diagnosis, regardless
of the issue of medical necessity.
(5) Requests which include a denial due to unrelated
injury/diagnosis may not proceed to medical dispute resolution based
on the denial of unrelatedness. However, requests which include a
denial based on medical necessity may proceed to medical dispute resolution
for the issue of medical necessity in accordance with subsection (o)
of this section.
(h) Except for requests submitted in accordance with
subsection (g) of this section, the insurance carrier shall approve
or deny requests based solely upon the medical necessity of the health
care required to treat the injury, regardless of:
(1) unresolved issues of compensability, extent of
or relatedness to the compensable injury;
(2) the insurance carrier's liability for the injury;
or
(3) the fact that the injured employee has reached
maximum medical improvement.
(i) The insurance carrier shall contact the requestor
or injured employee by telephone, facsimile, or electronic transmission
with the decision to approve or deny the request as follows:
(1) within three working days of receipt of a request
for preauthorization; or
(2) within three working days of receipt of a request
for concurrent review, except for health care listed in subsection
(q)(1) of this section, which is due within one working day of the
receipt of the request.
(j) The insurance carrier shall send written notification
of the approval or denial of the request within one working day of
the decision to the:
(1) injured employee;
(2) injured employee's representative; and
(3) requestor, if not previously sent by facsimile
or electronic transmission.
(k) The insurance carrier's failure to comply with
any timeframe requirements of this section shall result in an administrative
violation.
(l) The insurance carrier shall not withdraw a preauthorization
or concurrent review approval once issued. The approval shall include:
(1) the specific health care;
(2) the approved number of health care treatments and
specific period of time to complete the treatments; and
(3) a notice of any unresolved dispute regarding the
denial of compensability or liability or an unresolved dispute of
extent of or relatedness to the compensable injury.
(m) The insurance carrier shall afford the requestor
a reasonable opportunity to discuss the clinical basis for a denial
with the appropriate doctor or health care provider performing the
review prior to the issuance of a preauthorization or concurrent review
denial. The denial shall include:
(1) the clinical basis for the denial;
(2) a description or the source of the screening criteria
that were utilized as guidelines in making the denial;
(3) the principle reasons for the denial, if applicable;
(4) a plain language description of the complaint and
appeal processes, if denial was based on Labor Code §408.0042,
include notification to the injured employee and health care provider
of entitlement to file an extent of injury dispute in accordance with
Chapter 141 of this title (relating to Dispute Resolution--Benefit
Review Conference); and
(5) after reconsideration of a denial, the notification
of the availability of an independent review.
(n) The insurance carrier shall not condition an approval
or change any elements of the request as listed in subsection (f)
of this section, unless the condition or change is mutually agreed
to by the health care provider and insurance carrier and is documented.
(o) If the initial response is a denial of preauthorization
or concurrent review, the requestor or injured employee may request
reconsideration.
(1) The requestor or injured employee may within 30
days of receipt of a written initial denial request the insurance
carrier to reconsider the denial and shall document the reconsideration
request.
(2) The insurance carrier shall respond to the request
for reconsideration of the denial:
(A) as soon as practicable but not later than the 30th
day after receiving 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 (q)(1) of this section, which is due within
one working day of the receipt of the request.
(3) In addition to the requirements in this section,
the insurance carrier's reconsideration procedures shall include a
provision that the period during which the reconsideration is to be
completed shall be based on the medical or clinical immediacy of the
condition, procedure, or treatment.
(4) The requestor or injured employee may appeal the
denial of a reconsideration request regarding medical necessity by
filing a dispute in accordance with Labor Code §413.031 and related
division rules.
(5) A request for preauthorization for the same health
care shall only be resubmitted when the requestor provides objective
clinical documentation to support a substantial change in the injured
employee's medical condition or that demonstrates that the injured
employee has met clinical prerequisites for the requested health care
that had not been previously met before submission of the previous
request. The insurance carrier shall review the documentation and
determine if any substantial change in the injured employee's medical
condition has occurred or if all necessary clinical prerequisites
have been met. A frivolous resubmission of a preauthorization request
for the same health care constitutes an administrative violation.
(p) Non-emergency health care requiring preauthorization
includes:
(1) inpatient hospital admissions, including the principal
scheduled procedure(s) and the length of stay;
(2) outpatient surgical or ambulatory surgical services
as defined in subsection (a) of this section;
(3) spinal surgery;
(4) all work hardening or work conditioning services
requested by:
(A) non-exempted work hardening or work conditioning
programs; or
(B) division exempted programs if the proposed services
exceed or are not addressed by the division's treatment guidelines
as described in paragraph (12) of this subsection;
(5) physical and occupational therapy services, which
includes those services listed in the Healthcare Common Procedure
Coding System (HCPCS) at the following levels:
(A) Level I code range for Physical Medicine and Rehabilitation,
but limited to:
(i) Modalities, both supervised and constant attendance;
(ii) Therapeutic procedures, excluding work hardening
and work conditioning;
(iii) Orthotics/Prosthetics Management;
Cont'd... |
