Navigating Utilization Review Time Frames: A Guide for Healthcare Providers

Introduction:

As a healthcare provider involved in workers' compensation cases, understanding Utilization Review time frames is crucial for ensuring timely authorization of treatment. Navigating the complexities of these time frames can be challenging, but it is essential to provide prompt and necessary care to your patients. In this blog post, we will provide a comprehensive guide for healthcare providers on how to navigate Utilization Review time frames effectively.

Understanding the Regulations:

Familiarize yourself with the relevant regulations, such as the California Code of Regulations, section 9792.9.1 and Labor Code section 4610(g)(1). These regulations set forth the time frames within which Utilization Review must issue a decision from the date the DWC Form RFA is received.

Receipt of DWC Form RFA:

According to the regulations, the RFA is considered received five (5) days after it is deposited in the mail. However, fax or email submissions are only considered received if sent prior to 5:30 P.M. Pacific Time on a business day.

Counting to Five with Business Days:

Once the RFA is deemed received, the counting of the five (5) business days begins on the day after receipt. It is important to distinguish between business days (weekdays excluding holidays) and calendar days to accurately calculate the deadline for issuing a Utilization Review decision.

Exceptions:

Exceptions exist for expedited decisions and extensions. Expedited reviews must be decided within 72 hours after receiving the necessary information. For cases requiring decisions within hours, the counting starts from the time of receipt. Extensions may be granted when additional information is requested, allowing up to 14 calendar days from the receipt of the RFA for the decision.

Communication of Utilization Review Decision:

Utilization Review decisions must be communicated to the requesting physician within 24 hours, even if relayed after 5:30 P.M. on the fifth business day. It is crucial to meet this communication requirement to ensure effective collaboration and timely patient care.

Conclusion:

By familiarizing yourself with Utilization Review time frames and adhering to the regulations, you can navigate the process more effectively as a healthcare provider. Timely authorization of treatment is essential to provide appropriate care to your workers' compensation patients. Remember, seeking legal advice from a qualified professional familiar with workers' compensation regulations in your jurisdiction is recommended for specific guidance.

Note: The information provided in this blog is for informational purposes only and should not be considered legal advice.

Contact: Meraki RCM Solutions, LLC
Phone: +1(562)375-0472
Email: info_us@merakircm.com

Tag: Medical Billing / workers compensation/ Denied Claims