Medical Treatment Preauthorization Form

Instructions


Please visit https://www.azica.gov/treatment-guidelines-faqs for additional information.
FORM SECTION WHO USES HOW TO FILE TIMING ADDITIONAL INFORMATION
SECTION I:
PROVIDER REQUEST FOR PREAUTHORIZATION		 Medical Provider A medical provider must submit a completed Request for Preauthorization (Section I) to the payer by U.S. mail, fax, or e-mail. No timing requirements. • Preauthorization is not required to ensure payment for reasonably required medical treatment or services. A  medical provider may, however, submit a Request for Preauthorization (Section I) to seek pre-approval of specified medical treatment/services for an injured employee.
• To request preauthorization, a medical provider should complete Section I  (Provider Request for  Preauthorization)  of the Medical Treatment    Preauthorization Form and attach documentation supporting the medical necessity and appropriateness of the requested treatment/services.
•  Before requesting preauthorization, the body part or condition being treated must have been accepted as compensable under Arizona’s workers’ compensation system.
SECTION II:
PAYER DECISION ON REQUEST FOR PREAUTHORIZATION		 Payer • A payer must issue a Decision on Request for Preauthorization (Section II) to the medical provider by using the provider’s preferred method of contact (as indicated by the provider in Section I).
• If requested medical treatment/services are denied in whole or in part, a payer must also send a copy of the Decision on Request for Preauthorization (Section II) to the injured employee or the injured employee’s attorney.		 • A payer must respond to Request for Preauthorization (Section I) no later than 7 business days after the request is received from a medical provider.
• If a payer timely requests an IME after receiving a Request for Preauthorization (Section I), the payer’s time for rendering a preauthorization decision is put on hold. The payer’s preauthorization decision must be issued no later than 7 business days after the final IME report is received by the payer.  The payer should promptly provide a copy of a final IME report to the provider.		 • A payer may respond to a Request for Preauthorization (Section I) by: (1) communicating its preauthorization decision to the provider (i.e.; approved, partially denied, or denied); (2) notifying the provider that the Request for Preauthorization (Section I) is incomplete; or (3) notifying the provider that an IME has been requested.
• To respond to a Request for Preauthorization (Section I), a payer should complete applicable parts of  Section  II  (Payer  Decision on Request for     Preauthorization)     of the Medical Treatment Preauthorization  Form. If applicable, the payer should attach a statement of the approved treatment/services and, if the requested treatment/services are denied in whole or in part, an explanation of the reasons for the denial or partial denial.
•   If a payer timely obtains an IME to support its decision, administrative peer review (under Section V) is unavailable. Review of a payer decision supported by an IME is available under A.R.S. § 23- 1061(J).   To  request  review  under  A.R.S.  §  23-1061(J),  the  injured employee   must   file   a   Request   for   Hearing   with   the   Industrial Commission of Arizona.
•  If  a  payer  fails  to  respond  to  a  Request  for  Preauthorization (Section I) within 7 business days, the provider or injured employee is permitted to bypass the reconsideration process (Sections III and IV) and immediately request administrative peer review (Section V).
•   If   a   payer   denies   (in   whole   or   in   part)   requested   medical treatment/services  that  are  supported  by  ODG,  the  provider  or injured employee is permitted to bypass the reconsideration process (Sections  III  and  IV)  and  immediately  request  administrative  peer review (Section V).
SECTION III:
PROVIDER OR EMPLOYEE REQUEST FOR RECONSIDERATION OF PAYER DECISION		 Medical Provider
or Injured
Employee		 A medical provider or injured employee must submit a Request for Reconsideration of Payer Decision (Section
III) to the payer using the payer’s preferred method of contact (as indicated by the payer in Section II).		 No timing requirements. •  To  request  reconsideration,  the  provider  or  injured  employee should: (1) complete Section III (Provider or Employee Request for Reconsideration   of   Payer   Decision)   of the   Medical   Treatment Preauthorization  Form;  (2)  attach a statement of the reasons and justifications supporting the request for reconsideration;  and  (3) attach   documentation   to   support   the   medical   necessity   and appropriateness    of    the    treatment/services    requested    (if    not previously done).
• If the payer: (1) failed to respond to a Request for Preauthorization (Section  I)  within  7  business  days  of  receipt  of  the  request  or  (2) denied (in whole or in part) treatment/services that are supported by ODG,  the  provider  or  injured  employee  is  not  required  to  seek reconsideration  (Sections  III  and  IV)  and  may  immediately  request administrative peer review (Section V).
FORM SECTION WHO USES HOW TO FILE TIMING ADDITIONAL INFORMATION
SECTION IV:
PAYER DECISION ON REQUEST FOR RECONSIDERATION		 Payer • A payer must submit a Decision on Request for Reconsideration (Section IV) to the medical provider by using the provider’s preferred method of contact (as indicated by the provider in Section I).
• If requested medical treatment/services are denied in whole or in part, a payer must also send a copy of the Decision on Request for Reconsideration (Section IV) to the injured employee or the injured employee’s attorney.		 • A payer must respond to Request for Reconsideration (Section III) no later than 7 business days after the request is received from a medical provider.
• If a payer timely requests an IME after receiving a Request for Reconsideration (Section III), the payer’s time for rendering a reconsideration decision is put on hold. The payer’s reconsideration decision must be issued >no later than 7 business days after the final IME report is received by the payer.  The payer should promptly provide a copy of a final IME report to the provider.		 • A payer may respond to a Request for Reconsideration (Section III) by:  (1)  communicating  its  reconsideration  decision  to  the  provider (i.e.;  approved,  partially  denied,  or  denied);  or  (2)  notifying  the provider that an IME has been requested.
• To respond to a Request for Reconsideration (Section III), a payer should  complete  applicable  parts  of  Section  IV  (Payer  Decision  on Request     for     Reconsideration)     of     the     Medical     Treatment Preauthorization  Form.    If  applicable,  the  payer  should  attach  a statement of the approved treatment/services and, if the requested treatment/services are denied in whole or in part, an explanation of the reasons for the denial or partial denial.
•   If   a   payer   timely   obtains   an   IME   to   support   its   decision, administrative peer review (under Section V) is unavailable.  Review of a payer decision supported by an IME is available under A.R.S. § 23- 1061(J).   To  request  review  under  A.R.S.  §  23-1061(J),  the injured employee must   file   a   Request   for   Hearing   with   the   Industrial Commission of Arizona.
• If a payer fails to respond to a Request for Reconsideration (Section
III)  within  7  business  days,  the  provider  or  injured  employee  is permitted to request administrative peer review (Section V).
SECTION V:
PROVIDER OR EMPLOYEE REQUEST FOR ADMINISTRATIVE PEER REVIEW		 Medical Provider
or Injured
Employee		 • A medical provider or injured employee must submit a Request for Administrative Peer Review (Section V) to the Industrial Commission of Arizona, Medical Resource Office electronically through the MRO Portal (preferred) or by mail, fax, or e-mail.
• MRO Portal: https://mro.azica.gov/
• E-mail: [email protected]
• Fax: (602)-542-4797
• U.S. Mail:
Medical Resource Office 800 W. Washington. St. Phoenix, AZ 85007		 No timing requirements. •  The  administrative  peer  review  process  includes  a  peer  review performed  by  a  third-party,  URAC  accredited  peer-review  vendor. The peer reviewer must:  (1)  hold  an  active,  unrestricted  license  or certification  to  practice  medicine  or  a  health  profession;  (2)  have actively  practiced  medicine  or  a  health  profession  during  the  five preceding  years;  and  (3)  be  in  the  same  profession  and  the  same specialty  or  subspecialty  as  typically  performs  or  prescribes  the medical treatment/services requested.
• Although the administrative peer review process is administered by the Industrial Commission of Arizona,  Medical Resource Office, the payer  is  responsible  for  paying  the  costs  of  the  third-party  peer review.
•  A  medical  provider  or  injured  employee  may  file  a  >Request  for Administrative    Peer    Review    (Section    V)    in    the    following circumstances: (1) the payer failed to timely respond to a Request for Preauthorization (Section I) or Request for Reconsideration of Payer Decision  (Section  III);  (2)  the  payer  denied  (in  whole  or  in  part)  a Request   for   Preauthorization   (Section   I)   for   treatment/services supported  by ODG;  or (3)  the  payer  denied  (in  whole  or  in  part)  a Request for Reconsideration of Payer Decision (Section III).
•  To  submit  a  request  for  administrative  peer  review,  the  medical provider   or   injured   employee   should:   (1)   complete   Section   V (Request for Administrative Peer Review) of the Medical Treatment Preauthorization  Form;  (2)  attach  copies  of  all  relevant  medical records and, if applicable, documentation related to a payer’s non- response; and (3) attach copies of all documentation and statements previously attached to Sections I through IV.
•  If  the  payer  obtained  an  IME  to  support  a  preauthorization  or reconsideration decision, administrative peer review (under Section
V) is unavailable. Review of a payer decision supported by an IME is available under A.R.S. § 23-1061(J).  To request review under A.R.S. § 23-1061(J), the injured employee must file a Request for Hearing with the Industrial Commission of Arizona.

 

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