Prior Authorization

This is the determination of benefit coverage before services are provided to an injured worker. It is based on medical necessity and eligibility and it addresses the clinical appropriateness of the services or procedures based on the type, frequency, extent and duration.

Prior authorization for payment is requested by the authorized treating provider when:

• The Medical Treatment Guidelines or the Medical Fee Schedule specify that prior authorization is
  required for that service or
• A prescribed service
• ~ Exceeds the recommended limitations in the Medical Treatment Guidelines; or
• ~ Is not identified in the Medical Fee Schedule such as an unlisted procedure or service

Examples of services and/or procedures that require authorization include non-emergent hospitalization and surgery. Routine services such as physical therapy do not require prior authorization when they are an open and active claim and fall within the Treatment Guidelines.

Prior authorization may be requested utilizing the Division of Workers’ Compensation (DOWC) form WC188 – Authorized Treating Provider’s Request for Prior Authorization. The form requires the medical justification for treatment or procedures beyond the guideline recommendation. For unlisted procedures without relative
values in the fee schedule or listed as “by report”, the required procedure and payment request are to be specified on the form and accompanied by documentation.

Pinnacol will review the request and respond within ten calendar days from the completed request. Per Rule 16-7(2)(E), failure to timely respond to the completed request within ten calendar days is deemed authorization unless the payer has scheduled an IME and notified the requesting provider within the time prescribed for responding.

When the indicators of the Treatment Guidelines are met, NO prior authorization is required from Pinnacol.

Notification to Treat

An optional DOWC treatment notification process to guarantee payment for treatments or services that

• Have an established value in the Medical Fee Schedule; and
• Are consistent with the Medical Treatment Guidelines.

The DOWC WC 195 - “Notification by an Authorized Treating Provider (ATP)" requires documentation of the specific Medical Treatment Guidelines applicable to the proposed treatment or service and a certification that the proposed treatment/service is medically necessary and consistent with the Medical Treatment Guidelines. Supporting documentation must also be submitted as defined in Rule.

Pinnacol will review the verbal or written notification and respond within seven calendar days from the completed request and receipt of records. Pinnacol will respond verbally to verbal requests and will respond in writing if the provider uses the notification form or specifically requests a written response.

Remember, Pinnacol does not need the notification request when the service falls within the Treatment Guidelines and the service has a value in the Fee Schedule.

Using the notification form when services fall within the Treatment Guidelines can delay treatment of an injured worker as Pinnacol must review the notification request for payment verification. Payment may deny notification authorization when the proposed treatment

• Is not related to the admitted injury;
• Falls outside the Medical Treatment Guidelines;
• The medical records contain conflicting opinions among the ATPs;
• There is no admission of liability or final order finding the injury compensable has been issued;
• The submitting provider is not an authorized treating provider or is proposing treatment to be performed by a provider who is not eligible to be an authorized treating physician; or
• The injured worker is not entitled to the treatment pursuant to a statute or settlement.

Any provider or payer who incorrectly applies the Medical Treatment Guidelines in the Notification to Treat/Prior Authorization process may be subject to penalties under the Workers’ Compensation Act.

If you have any questions or need additional information, please contact Pinnacol Assurance at provider_management@pinnacol.com or 303.361.4945.‍

Colorado DOWC Utilization Standards, Rule 16

Colorado DOWC, Form WC188 and Form WC195