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Authorization and Declaration: RFAs and Liens Under SB 1160 (Part I)

December 6, 2016 by Catherine Montgomery

It’s something like a motto around here: Billing success starts with authorization success. Submitting a Request for Authorization (RFA) is the best investment a provider can make to guarantee payment for workers’ comp bills.

This has been the case since 2013, when Senate Bill 863 made RFAs mandatory.[1] Now, a new piece of legislation – Senate Bill 1160, covered extensively in this space – makes RFAs an indispensable part of lien claimant qualification, as well.

Remember, starting January 1, 2017, all medical treatment and med-legal lien claimants must file a lien declaration affirming that the claimant satisfies at least one of seven new lien claimant requirements. Of the seven, two prominently feature RFAs.

We’ll quote the relevant portion of the bill (Section 8, which amends Labor Code 4903.05) before examining the first of these requirements in greater detail.

For liens filed on or after January 1, 2017, any lien claim for expenses under subdivision (b) of Section 4903 that is subject to a filing fee under this section shall be accompanied at the time of filing by a declaration stating, under penalty of perjury, that the dispute is not subject to an independent bill review and independent medical review under Sections 4603.6 and 4610.5, respectively, that the lien claimant satisfies one of the following:

  1. Is the employee’s treating physician providing care through a medical provider network
  2. Is the agreed medical evaluator or qualified medical evaluator.
  3. Has provided treatment authorized by the employer or claims administrator under Section 4610.
  4. Has made a diligent search and determined that the employer does not have a medical provider network in place.
  5. Has documentation that medical treatment has been neglected or unreasonably refused to the employee as provided by Section 4600.
  6. Can show that the expense was incurred for an emergency medical condition, as defined by subdivision (b) of Section 1317.1 of the Health and Safety Code.
  7. Is a certified interpreter rendering services during a medical-legal examination, a copy service providing medical-legal services, or has an expense allowed as a lien under rules adopted by the administrative director.[2]  

Section C

Once a claims administrator receives a compliant RFA from a provider, it must respond with a compliant and timely communication to that provider that approves, modifies, or denies the requested treatment.[3] Claims administrators communicate the decision within five business days, except in the case of an expedited or retrospective Utilization Review (UR) decision.

Keeping a record of the claims administrator’s receipt of the RFA is critical. DaisyBillers, in the RFA History page, you can find the precise date and time that the RFA decision is due back from the claims administrator, along with a fax receipt verifying delivery. An untimely response to an RFA invalidates the utilization decision and allows the WCAB to decide the treatment dispute.

We can’t stress this enough: RFAs are required, easy to track, and an approved RFA allows you to file a lien.

Summary

Authorized RFAs guarantee payment, and guarantee that you may file a lien under Section C.

Untimely responses to RFAs invalidate the utilization decision and allow the WCAB to decide the treatment dispute.

Every physician should invest in RFAs – they’re the most effective way to ensure payment.


If you’d like to learn more about how DaisyBill’s RFA generator quickly and easily boosts revenue, sign up for a demo with one of our workers’ comp billing experts.

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[1] Need to do some serious catch-up? The DWC overview of SB 863 can be found here.

[2] Full text of SB 1160 here.

[3] Prior to January 1, 2017, the claims administrator may also delay the requested treatment.

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