Utilization management

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Pinnacol Assurance's SelectNet Provider Manual was recently updated to be more user-friendly regarding utilization management procedures in compliance with the Colorado Division of Workers' Compensation Rules. As a reminder, according to the Treatment Guidelines (Rule17), in admitted claims where treatment falls within the purview of a medical treatment guideline, prior authorization for payment under Rule 16-9 is unnecessary unless the guideline specifies otherwise.

In accordance with Pinnacol's existing gatekeeper model and the SelectNet Manual's Participation Guidelines, the provider who receives the referral should not contact Pinnacol for prior authorization for payment. If additional treatment in excess of the original PCP's prescription is recommended by the provider receiving the referral, 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.

If you have any additional questions regarding this process, please contact your provider relations specialist at (303) 361-4945, and we'll be happy to assist you.