A provider’s office recently asked if claims administrators must sign and return the Division of Workers’ Compensation (DWC)’s official RFA form when approving the requested treatment.

California regulations do not require the claims administrator to respond to an RFA using any particular form, but the regulations require a written utilization review decision to include specific information. Providers need know what constitutes an appropriate, compliant written utilization review response.

While the regulations essentially require providers to use DWC Form RFA, claims administrators are free to use their own forms or authorization letters when issuing a utilization review decision.

Even though the RFA form includes a section entitled “Claims Administrator/Utilization Review Organization (URO) Response” where the the claims administrator can indicate approval, denial, or modification for the requested treatment, along with comments,* the use of this section is optional.

1. The date on which the DWC Form RFA was first received.
2. The date on which the decision is made.
3. A description of the specific course of proposed medical treatment for which authorization was requested.
4. A list of all medical records reviewed.
5. A specific description of the medical treatment service approved, if any.
6. A clear, concise, and appropriate explanation of the reasons for the reviewing physician's decision, including the clinical reasons regarding medical necessity and a description of the relevant medical criteria or guidelines.
7. The written decision modifying, delaying or denying treatment authorization provided to the requesting physician shall also contain the name and specialty of the reviewer or expert reviewer, and the telephone number in the United States of the reviewer or expert reviewer.

Providers should always review modified or denied utilization review decision to confirm that written decisions conveys the required information.

When utilization review approves the request for treatment, CCR §9792.9.1 requires the written decision to include the following information:

1. The specific the date the complete request for authorization was received,
2. The medical treatment service requested,
3. The specific medical treatment service approved, and
4. The date of the decision

A compliantly approved and communicated utilization review decision guarantees payment for the authorized services.

For DaisyBill clients, our Billing Software automatically identifies the date a utilization review decision is due in response to a provider’s RFA. We alert the provider if a utilization review decision is untimely, but we cannot read the content of the actual decision. All providers need to carefully review the utilization review decision for compliant content.

While the claims administrator may not be held to a particular form, they still play a role in ensuring appropriate treatment and proper reimbursement. For their own protection, providers should be aware of the claims administrator’s requirements as well as their own.

Want to make RFA’s easy? There’s a SaaS for that. DaisyBill’s Billing Software generates instant, compliant RFA’s. Our software tracks the requests, and keeps the provider informed of response due dates. To see more, schedule a free demonstration today.

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