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.
To request authorization for proposed treatment, the DWC essentially requires providers to use the official DWC Form RFA. CCR § 9792.9.1(c)(2)(B) states that the claims administrator “may accept a request for authorization for medical treatment that does not utilize the DWC Form RFA…” provided it has all the required information. The words “may accept” mean that providers must use the DWC Form RFA unless the claims administrator says otherwise.
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.
Even though a claims administrator is not required to return the RFA form when responding to a request for authorization, the claims administrator must always respond to the RFA by sending a provider a timely written utilization review decision. When the request for treatment is modified or denied, per CCR §9792.9.1. the following is a checklist of information that must be included in the written utilization decision:
- The date on which the DWC Form RFA was first received.
- The date on which the decision is made.
- A description of the specific course of proposed medical treatment for which authorization was requested.
- A list of all medical records reviewed.
- A specific description of the medical treatment service approved, if any.
- 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.
- 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:
- The specific the date the complete request for authorization was received,
- The medical treatment service requested,
- The specific medical treatment service approved, and
- 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.
Providers can request expedited authorization without using DWC Form RFA.
(5) The written decision modifying, delaying or denying treatment authorization shall be provided to the requesting physician, the injured worker, the injured worker's representative, and if the injured worker is represented by counsel, the injured worker's attorney. The written decision shall be signed by either the claims administrator or the reviewer, and shall only contain the following information specific to the request:
(A) The date on which the DWC Form RFA was first received.
(B) The date on which the decision is made.
(C) A description of the specific course of proposed medical treatment for which authorization was requested.
(D) A list of all medical records reviewed.
(E) A specific description of the medical treatment service approved, if any.
(F) 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 used to reach the decision pursuant to section 9792.8. If a utilization review decision to modify, deny or delay a medical service is due to incomplete or insufficient information, the decision shall specify the reason for the decision and specify the information that is needed.
(G) The Application for Independent Medical Review, DWC Form IMR. All fields of the form, except for the signature of the employee, must be completed by the claims administrator. The written decision provided to the injured worker, shall include an addressed envelope, which may be postage-paid for mailing to the Administrative Director or his or her designee. Prior to March 1, 2014, any version of the DWC Form IMR adopted by the Administrative Director under section 9792.10.2 may be used by the claims administrator in a written decision modifying, delaying or denying treatment authorization.
(H) A clear statement advising the injured employee that any dispute shall be resolved in accordance with the independent medical review provisions of Labor Code section 4610.5 and 4610.6, and that an objection to the utilization review decision must be communicated by the injured worker, the injured worker's representative, or the injured worker's attorney on behalf of the injured worker on the enclosed Application for Independent Medical Review, DWC Form IMR, within 30 calendar days after service of the decision.
(I) Include the following mandatory language advising the injured employee:
“You have a right to disagree with decisions affecting your claim. If you have questions about the information in this notice, please call me (insert claims adjuster's or appropriate contact's name in parentheses) at (insert telephone number). However, if you are represented by an attorney, please contact your attorney instead of me.
“For information about the workers' compensation claims process and your rights and obligations, go to www.dwc.ca.gov or contact an information and assistance (I&A) officer of the state Division of Workers' Compensation. For recorded information and a list of offices, call toll-free 1-800-736-7401.”
(J) Details about the claims administrator's internal utilization review appeals process for the requesting physician, if any, and a clear statement that the internal appeals process is voluntary process that neither triggers nor bars use of the dispute resolution procedures of Labor Code section 4610.5 and 4610.6, but may be pursued on an optional basis.
(K) 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. The written decision shall also disclose the hours of availability of either the reviewer, the expert reviewer or the medical director for the treating physician to discuss the decision which shall be, at a minimum, four (4) hours per week during normal business hours, 9:00 AM to 5:30 PM., Pacific Time or an agreed upon scheduled time to discuss the decision with the requesting physician. In the event the reviewer is unavailable, the requesting physician may discuss the written decision with another reviewer who is competent to evaluate the specific clinical issues involved in the medical treatment services.