this is great!! (California)

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this is great!! (California)

Postby feelin it on Mon Mar 02, 2009 11:02 am

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Re: this is great!!

Postby davidd on Mon Mar 02, 2009 11:17 am

Thanks Ken - I hope everyone likes the new forums. I'm still in the process of writing up some tips and tricks. Hopefully everything goes smooth...
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Re: this is great!! (California)

Postby feelin it on Mon Mar 02, 2009 12:13 pm

David thanks for the help !1
My question to the forum is if I go to see an AME then scif does not abide by it can they just keep sending me back for re-evals ?
Can I tell the doc that they are not auth. treatment per his report?

thanks feelin it
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Re: this is great!! (California)

Postby TC on Mon Mar 02, 2009 1:30 pm

The PTP controls treatment. The AME can opine many things, but the treatment issue does not arise until the PTP makes a treatment request. 4600 indicates treatment is subject to UR - 4610. The UR regulations only specify four kinds of documents (treatment requests) subject to the UR time limits, and all of these are from the PTP.
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Re: this is great!! (California)

Postby feelin it on Mon Mar 02, 2009 2:22 pm

PTP has requested treatment for all .
scif usually just does not send to U.R.
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Re: this is great!! (California)

Postby TC on Mon Mar 02, 2009 8:32 pm

You wrote: "PTP has requested treatment for all . scif usually just does not send to U.R."
In UR there are (a) expedited reviews; (b) prospective (or concurrent) reviews; and (c) retrospective reviews.
I presume your case involves prospective review.
Insuers and self-insureds receive millions of medical documents annually.
Only certain medical treatment requests are subject to the UR timelines.
In UR, the prospective review time limits, only apply to:
(1) Doctor's First report; (2) PR-2; (3) a PR-2 narrative with the words "treatment request" clearly written at the top of the page; and (4) written confirmation (in a Doctor's First or PR-2) within 72 hours of an oral request for a specific course of medical treatment. See 8 CCR 9792.6(o).
IF your PTP has made a "treatment request" as defined by 8 CCR 9792.6(o), and IF there was no timely UR performed by the insurer, then file a DOR for an expedited hearing. However, UR departments typically do not review treatment requests which do not meet the regulatory definition. [Remember, they get millions of medical documents annually.] It seems unusal to repeatedly not send requests to UR. So, I have a suspicion the PTP may not have submitted treatment requests as defined by the regulations.
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Re: this is great!! (California)

Postby doublecrush on Thu Mar 05, 2009 1:51 pm

This is a nice forum DavidD. Would like to spend some time but have to go to a doc appt. this afternoon. Had a hard time finding an avator within the size limitations though. Thank you for upgrading! :P
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Re: this is great!! (California)

Postby feelin it on Thu Mar 05, 2009 2:04 pm

Hey doublecrush nice to see that you are still around !!
hope all is well feelin it
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