When we published Telehealth Cheat Sheet: California Providers’ Guide, many providers reached out to us with questions regarding authorization requirements. For clarification, the California workers’ comp utilization review requirements have not changed. Every medical treatment requires utilization review whether the medical treatment is delivered in person or delivered via telehealth video.

For California workers’ comp, 30 days after the initial work injury or illness, every medical treatment requires the provider to submit a Request for Authorization (RFA) to the claims administrator for utilization review.

Whether the service is delivered via telehealth or in-person, the same authorization requirement still holds. For example, the DWC allows providers to furnish all of the treatment listed on the Medicare List of Telehealth Services via a video connection. As with other services, prior to furnishing any of the treatment on the Medicare List of Telehealth Services, the provider must still submit a compliant Request for Authorization to the claims administrator for approval to furnish the treatment.

Note, however, that the method of delivering the requested medical treatment does not require separate authorization. When furnishing a service via telehealth, a provider only needs to submit the normally-required RFA for that service; the provider does not need a separate or different authorization for providing the service via telehealth.

California Division of Industrial Relations maintains a helpful FAQ webpage that explains workers’ comp medical treatment utilization review requirements. All stakeholders are encouraged to read through these FAQs to familiarize themselves with these requirements.

Q. What is utilization review (UR) and why is it used for workers' compensation?

A. UR is the process used by employers or claims administrators to determine if a proposed treatment requested for an injured worker is medically necessary. All employers or their workers' compensation claims administrators are required by law to have a UR program. This program is used to decide whether or not to approve medical treatment recommended by a treating physician.

Q. Is utilization review required in every case?

A. Yes. The California Supreme Court held that utilization review must be used for every medical treatment request in the California workers' compensation system. The court also held that approving requested treatment without physician review is part of utilization review (UR), and only reviewing physicians may decide to delay, deny, or modify requested treatment. The UR regulations allow an employer to reduce the cost of physician review in UR by designing a "prior authorization" program within the employer's UR plan. (See below: About prior authorization.)

Resources

Here at DaisyBill, we have written extensively on the topic of authorization. Below is a list of links to our published material, including links explaining “automatic authorization” for the first 30-days of an injury or illness.

• 02/18/2020 3 Workers’ Comp Authorization Myths, Debunked
• 06/22/2018 Conditional Authorization: How MPNs Cheat Workers’ Comp Providers
• 04/25/2018 3 Facts About Automatic Authorization for Workers’ Compensation
• 03/09/2018 Complete 2018 Automatic Authorization Guide for California Workers’ Comp
• 01/12/2018 Authorization 2018: New Billing and RFA Deadlines
• 01/05/2018 Authorization: 6 Qualifying Conditions for Fast-track Automatic Authorization
• 12/14/2017 In Workers' Comp, Authorization Is Final
• 07/20/2017 Consultation Codes Not Payable Without Authorization
• 06/29/2017 Don’t Be Fooled: Authorization Guarantees Payment

Summary of Telehealth for CA Workers’ Compensation (Physician Services)

For more on telehealth rules for Medicare, California health insurers, and California workers’ compensation, look through the free resources available on our COVID-19 page.

FREE TELEHEALTH RESOURCES