Obtaining Authorizations – How the Process Works
By Liana Dyson, Claims Specialist, Pinnacol Assurance
Pinnacol Assurance employees often field questions on how the authorization process works. There are three basic situations that require prior authorization:
- Anything outside the guidelines
- Anything exceeding the treatment guideline limitations
- Anything in the guidelines that specifically requires preauthorization (for example, surgery or certain types of ancillary treatment)
The official wording reads: In admitted claims where treatment falls within the purview of a Colorado Division of Workers’ Compensation (DOWC) Medical Treatment Guideline, prior authorization for payment under Rule 16-9 is unnecessary unless the guideline specifies otherwise.
If additional treatment in excess of the original primary care physician’s prescription is recommended by the provider receiving the referral, the provider who receives the referral should not contact Pinnacol for prior authorization for payment. In accordance with Pinnacol’s existing gatekeeper model and the SelectNet Manual’s Participation Guidelines, the PCP and the provider can discuss the specific treatment goals, including functional gains and medical necessity of the additional treatment. If the PCP agrees with the additional treatment, then prior authorization for payment is required only if the treatment exceeds the limitations of the DOWC Treatment Guidelines.
The authorization process at Pinnacol starts with a request from the provider. Pinnacol claims representatives review the request for relatedness and medical necessity. The authorization or denial will be made within seven business days from the receipt of a routine request. In the case of an emergent procedure, the treatment should be given and a retroactive authorization sought from Pinnacol. Lack of authorization should not delay treatment if it is an emergency. However, the authorization may be denied, and the patient may need to seek retroactive authorization through private insurance.
There are situations where utilization review or medical case management may be required. Requests outside of the guidelines and those for complicated surgeries will be reviewed. If there is a question of how much of the pathology is related to the current injury versus pre-existing condition, these cases will be evaluated. Requests for experimental or unproven procedures and equipment will also be reviewed.
In cases being reviewed for compensability, an investigation will be done by the claims representative as quickly as possible. In each situation this may include, but not be limited to, contact with the policyholder, injured worker and any witnesses. Prior medical history and medical releases may also be requested. In other cases, an independent medical exam may be requested.
To learn more about the authorization process and talk with Pinnacol experts, attend the Obtaining Authorizations session at Pinnacol’s Healthcare Conference on Sept. 29 in Denver or Oct. 7 in Grand Junction.