| (2) three working days of receipt of a request for
concurrent utilization 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 of the request, adverse determination on the request,
or denial of the request under subsection (g) of this section because
of an unrelated injury or diagnosis 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 utilization 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;
(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; and
(4) the insurance carrier's preauthorization approval
number that conforms to the standards described in §19.2009(a)(4)
of this title (relating to Notice of Determinations Made in Utilization
Review).
(m) In accordance with §19.2010 of this title
(relating to Requirements Prior to Issuing Adverse Determination),
the insurance carrier shall afford the requestor a reasonable opportunity
to discuss the clinical basis for the adverse determination prior
to issuing the adverse determination. The notice of adverse determination
must comply with the requirements of §19.2009 of this title and
if preauthorization is denied under Labor Code §408.0042 because
the treatment is for an injury or diagnosis unrelated to the compensable
injury the notice must 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).
(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 an adverse determination
of preauthorization or concurrent utilization review, the requestor
or injured employee may request reconsideration orally or in writing.
A request for reconsideration under this section constitutes an appeal
for the purposes of §19.2011 of this title (relating to Written
Procedures for Appeal of Adverse Determinations).
(1) The requestor or injured employee may within 30
days of receipt of a written adverse determination request the insurance
carrier to reconsider the adverse determination and shall document
the reconsideration request.
(2) The insurance carrier shall respond to the request
for reconsideration of the adverse determination:
(A) as soon as practicable but not later than the 30th
day after receiving a request for reconsideration of an adverse determination
of preauthorization; or
(B) within three working days of receipt of a request
for reconsideration of an adverse determination of concurrent utilization
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
and §19.2011 of this title, 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) In any instance where the insurance carrier is
questioning the medical necessity or appropriateness of the health
care services prior to the issuance of an adverse determination on
the request for reconsideration, the insurance carrier shall comply
with the requirements of §19.2010 and §19.2011 of this title,
including the requirement that the insurance carrier afford the requestor
a reasonable opportunity to discuss the proposed health care with
a doctor or, in cases of a dental plan or chiropractic services, with
a dentist or chiropractor, respectively.
(5) The requestor or injured employee may appeal the
denial of a reconsideration request regarding an adverse determination
by filing a dispute in accordance with Labor Code §413.031 and
related division rules.
(6) 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;
(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;
(iv) Other procedures, limited to the unlisted physical
medicine and rehabilitation procedure code; and
(B) Level II temporary code(s) for physical and occupational
therapy services provided in a home setting;
(C) except for the first six visits of physical or
occupational therapy following the evaluation when such treatment
is rendered within the first two weeks immediately following:
(i) the date of injury; or
(ii) a surgical intervention previously preauthorized
by the insurance carrier;
(6) any investigational or experimental service or
device for which there is early, developing scientific or clinical
evidence demonstrating the potential efficacy of the treatment, service,
or device but that is not yet broadly accepted as the prevailing standard
of care;
(7) all psychological testing and psychotherapy, repeat
interviews, and biofeedback, except when any service is part of a
preauthorized return-to-work rehabilitation program;
(8) unless otherwise specified in this subsection,
a repeat individual diagnostic study;
(A) with a reimbursement rate of greater than $350
as established in the current Medical Fee Guideline; or
(B) without a reimbursement rate established in the
current Medical Fee Guideline;
(9) all durable medical equipment (DME) in excess of
$500 billed charges per item (either purchase or expected cumulative
rental);
(10) chronic pain management/interdisciplinary pain
rehabilitation;
(11) drugs not included in the applicable division
formulary;
(12) treatments and services that exceed or are not
addressed by the commissioner's adopted treatment guidelines or protocols
and are not contained in a treatment plan preauthorized by the insurance
carrier. This requirement does not apply to drugs prescribed for claims
under §§134.506, 134.530 or 134.540 of this title (relating
to Pharmaceutical Benefits);
(13) required treatment plans; and
(14) any treatment for an injury or diagnosis that
is not accepted by the insurance carrier under Labor Code §408.0042
and §126.14 of this title (relating to Treating Doctor Examination
to Define the Compensable Injury).
(q) The health care requiring concurrent utilization
review for an extension for previously approved services includes:
(1) inpatient length of stay;
Cont'd... |
