When may a claims administrator deny a request for authorization without first sending the RFA to a physician reviewer in UR?
A. When an RFA is submitted first to the claims administrator and the claims administrator has already made a valid written non-medical objection; – or – When an employer has an MPN and the claims administrator has already notified the injured worker in writing that the specific treatment requested in the RFA is authorized and must be provided by an appropriate MPN physician of the worker’s choice within the MPN. If the RFA is sent directly to the URO, the URO must complete the physician review process (i.e. medical necessity determination); the URO may not return the RFA to the claims administrator without completing its medical necessity determination unless the specific treatment requested in the RFA was already authorized in writing. The claims administrator may not direct the URO to disregard a request for authorization received by the URO unless the claims administrator can produce a valid prior objection or written authorization as described below. In the case of a valid prior o
Related Questions
- May the claims administrator deny a request for authorization because the treating physician is not the MPN physician?
- May a URO deny a request for authorization because the treating physician is not the MPN physician?
- What are the possible determinations when a review request is sent to a physician peer reviewer?
