Please visit https://www.azica.gov/treatment-guidelines-faqs for additional information. |
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| 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. |