When you suffer an injury or illness at work, it is important to receive the necessary medical treatment to help get you healthy and back to work. A doctor or a physician will be responsible for requesting your treatment.
For a physician to obtain medical treatment authorization, the requesting physician must submit a compliant Request For Authorization (RFA) to the claims administrator. In response, if the claims administrator does not authorize the treatment request, the RFA is sent to an accredited Utilization Review (UR) company to approve, modify, or deny the requested treatment. Whatever the outcome, claims administrators or the utilization review company must timely and correctly respond to the RFA.
A treating physician submits an RFA to request authorization as follows:
- Prospectively – before providing treatment; UR decision is due 5 business days of receipt of RFA
- Concurrently – currently providing treatment or during an inpatient stay; 5 business days receipt of RFA
- Retrospectively – after providing treatment; 30 calendar days of receipt of RFA
In the case of an immediate and serious threat to the patient’s health, a requesting physician may request expedited utilization review for a prospective or a concurrent RFA and the decision is due 72 hours of receipt of written information reasonably necessary to make the determination.