Pre-Authorization Requests (California)

[paduanow@yahoo.com]

I don't know if everybody else is having issues when your sending the PreAuthorization request via fax or by mail or both and never, every get a reply. Then you bill for your services and get an EOR for PA not obtained, services not authorized and so on! This is becoming the standard, not the exception. Only 15% of our request get an answer.

We mail 15 to 30 days in advance for request and FAX this information too! We include the fax confirmation sheet and authorization with the billing.

Is there anything else I can do?

Is anyone else having the same problem?

paduanow

[stevepsca]

I'm not 'legal'... but on various message boards I'm getting the same question over and over..."What do I do when the CA won't send a PR-2 to UR?"...

If you are not the PTP, UR/CA doesn't even have to respond to your request for PR. If you are PTP, and UR is not being used, then the IW/AA should file the DOR for MSC/hearing, and file a A/U referral with the medical dir.

Is there anything else I can do? IMHO...Your services are on 'green lien' if you believe there is medical necessity and MTUS/ACOEM/ODG reference.

A I&A told me the dir is asking for claims/info on CA failure to use UR, and frivilous use of UR process. So AU is looking at this.
Another IW just told me the ALJ slapped SCIF/CA with (angrily) penalties and sanctions (fairly large..whatever that means) for failure to respond to PR-2 and UR process.

This is becoming the standard, not the exception that's right. But why use UR at what... $300 a crack, when the 5814 self imposed is only 10%....?

[missygiordano]

Hi Steve,

I respectfully disagree with your assertion that "If you are not the PTP, UR/CA doesn't even have to respond to your request for PR."

The DWC website, under the Claims Examiner FAQ's page( http://www.dir.ca.gov/dwc/UtilizationRe ... _FAQ.htm#6) notes the following:

Q. Do we have to respond to a secondary physician’s request for authorization?

A. Yes. You must respond to any written request for authorization from any physician (written on 5021 or PR-2 or narrative format with same information) (8 CCR § 9792.6(o)) If necessary, concurrent with the UR process, you may also contact the primary treating physician to confirm the referral for treatment to the secondary physician.

[stevepsca]

ThankX 'missy'... I appreciate that info.
I can't tell you how many times I, and many other IW's have experienced this, and/or failure to apply the UR process at all. Your info provides basis for about 50+ AU referrals. No kidding...
Appearantly that CA FAQ needs to be included in the employee handbook...specifically for a few of those at SCIF.(not all)

Do you know/have the authority that answer is based on? The 8 CCR § 9792.6(o) only says the request must be in writing. I've not seen basis for the answer to FAQ #6 in a LC or CCR. I would appreciate that authority to use in my AU referral/s.
Thanks again.