Presumptive authorization

BWC has established a program giving providers presumptive authorization to provide specific medical services without waiting for prior authorization from the managed care organization (MCO). For a period not to exceed 60 days after the date of injury, physicians have presumptive authorization to provide specific medical services without waiting for prior authorization from the MCO.

For a period not to exceed 60 days after the date of injury, physicians have presumptive authorization to provide the following services when treating soft tissue and musculoskeletal injuries that are allowed conditions in claims:

• A maximum of 10 physical medicine visits, including osteopathic, chiropractic, physical therapy, occupational therapy and transitional work on-site therapy services;
• Diagnostic studies, including X-rays, CAT scans, MRI scans and EMG/NCV;
• Injections, up to three soft-tissue or joint injections (does not include epidural injections);
• Evaluation/management services and consultation services.

Providers must meet the following criteria before initiating any or all of the above services:

• Must file the FROI with the MCO);
• Complete and file the Physician’s Request for Authorization of Medical Services or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease (C-9) with the MCO. MCOs notify providers within three business days that they received the C-9, and reviewed it to ensure that services being rendered are medically necessary for the claim allowance;
• Notify the MCO within 24 hours of treatment if the injured worker will be off work for more than two calendar days.