What must the decisions to modify, delay or deny say?
A. In order to document the timeliness of the review, we recommend including the date that the written authorization request was received. The decision must be in writing and it must contain: 1. The date the decision was made 2. A description of the specific course of proposed medical treatment for which authorization was requested 3. A specific description of the medical treatment service approved, if any 4. A clear and concise explanation of the reasons for the claims administrator’s decision 5. A description of the medical criteria or guidelines used 6. The clinical reasons explaining why the treatment isn’t medically necessary 7. A clear statement that any dispute shall be resolved under LC 4062, and that an objection to the UR decision must be communicated to the claims administrator by the injured worker or the injured worker’s attorney in writing within 20 days of receipt of the decision. It shall further state that the 20-day time limit may be extended for good cause or by mutu
A. The following answer applies to decisions in which any of the medical treatment listed in the request for authorization (RFA) has been modified, denied or delayed. To document the timeliness of the review, we recommend stating the date of the decision letter and the date the RFA was received at the top of the letter.
