Requesting treatment authorization

To help the managed care organization (MCO) consider authorization and improve the bill payment process, BWC has implemented the following guidelines:

1. The physician of record or treating physician submits the treatment authorization request to the appropriate MCO before initiating any non-emergency treatment. The preferred method of submission is the Physician’s Request for Authorization of Medical Services or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease (C-9); however, you may use any other physician-generated document, provided the substitute document contains, at a minimum, the data elements on the C-9;
   
   
2. MCO must provide a decision to the physician within three business days The MCOs must fax the authorized, denied or pending treatment request. If they cannot fax their decision, they must call the physician and then follow up by mail;
   
   
3. If the MCO is unable to make a decision within three business days, because of a need for additional information and the physician is notified, the MCO will send a Request for Additional Medical Documentation (C-9-A) to the physician. MCOs have five business days from the date they receive the additional information to make a subsequent decision. The MCO may deny the treatment request if the physician does not provide any requested documentation within five business days as required by the provider agreement. The MCO must notify the physician of the subsequent decision by fax or telephone and follow up by mail; If the MCO is unable to make a decision within three business days because of a need for a medical review, the MCO must notify the physician. The medical review must take place and a decision made within five days. Again, the MCO must notify the physician of the subsequent decision by fax or telephone and follow up by mail;
   
   
4. A provider may initiate treatments when all of these criteria are met:
   • The MCO fails to communicate a decision to the physician within three business days of receiving the original treatment request or within five business days if the request is pending;
   • The physician has documented the treatment request completely and correctly on a C-9 or other acceptable document;
   • The physician has proof of submission to the appropriate MCO;
   • Treatment is for the allowed conditions;
   • The claim is in a payable status.
     
     
5. The MCO will authorize, deny or pend a provider’s proposed retroactive treatment request within 30 calendar days from receipt;
   
   
6. Self-insuring employers must approve or deny treatment plans within 10 days;
   
   
7. In instances where the MCO does not respond to the C-9 within three days and the provider initiates treatment, the MCO will provide concurrent and retro review. If the MCO decides the treatment is not necessary, the MCO will notify all parties that treatment should be discontinued. And the MCO will pay for services rendered up to that point.