Who must the decisions to modify, delay or deny be given to?
A. On both prospective and concurrent reviews, the decision must be given to the requesting physician initially by telephone or fax. The phone call must be followed by written notice to the requesting physician, the injured worker and the injured worker’s attorney (if applicable) within 24 hours of the decision for concurrent reviews, and within two business days of the decision for prospective reviews. If a fax is used in lieu of the phone call, and all mandated language is included in the fax, the written notification is satisfied. If the request for authorization also included a request that the injured worker receive goods or services from a non-physician, and contact information for that non-physician provider was given, a letter must also be sent to the non-physician provider. The letter shall include the decision modifying, delaying or denying the request for authorization but shall not include the rationale, criteria or guidelines used for the decision.
