SB 863 UR and IMR injury denied (California)

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SB 863 UR and IMR injury denied (California)

Postby compquest on Tue Sep 25, 2012 8:19 pm

If injury denied claim, does the defense still do UR under SB 863?

I have the impression :

No UR until AOE COE decided

If defense loses AOE COE then defense has 30 days to retro UR then IMR.
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Re: SB 863 UR and IMR injury denied (California)

Postby ozzie on Tue Sep 25, 2012 8:42 pm

My understanding is, no UR if denied body part or aoe/coe. But 30 days for retro? Have to read more!
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Re: SB 863 UR and IMR injury denied (California) (California)

Postby compquest on Tue Oct 09, 2012 6:53 pm

Labor code 4610 allows retro UR once the needed data is received. So if applicant wins on issue of injury, then 30 days later UR? Maybe that is the way under sb 863. I heard that view at a seminar. The other view was UR starts when applicant wins on injury AOE/COE when denied claim.
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Re: SB 863 UR and IMR injury denied (California)

Postby samcat on Tue Oct 09, 2012 8:20 pm

The claims administrator has an option to defer on performing UR/IMR pending the outcome of the AOE/COE, body part dispute at which time UR/IMR can be done retrospectively
Or
Perform UR/IMR when the RFA is originally submitted. This is what was informally previously known as "conditional UR".
In this instance, if the UR/IMR results in certifying the RFA the claims administrator must authorize the procedure if AOE/COE, body part dispute is resolved in favor of the IW. If the IW self procures the treatment the claims administrator must pay for the medical services.
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Re: SB 863 UR and IMR injury denied (California)

Postby compquest on Wed Oct 10, 2012 11:51 am

It seems that if AOE/ COE is denied that retrospective reviews might be better. However, they would have to organize the treatment requests so they could do a timely retrospective review which would seem to be 30 days from when applicant wins on the issue of injury AOE/ COE.
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