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1 Medical Authorization Tips for Providers - Overview When An Injured Worker Presents with a Form CA- 16 When An Injured Worker Presents with a Form CA-

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Presentation on theme: "1 Medical Authorization Tips for Providers - Overview When An Injured Worker Presents with a Form CA- 16 When An Injured Worker Presents with a Form CA-"— Presentation transcript:

1 1 Medical Authorization Tips for Providers - Overview When An Injured Worker Presents with a Form CA- 16 When An Injured Worker Presents with a Form CA- 16 Services that require authorization Services that require authorization Submitting an authorization request Submitting an authorization request Information required to process an authorization Information required to process an authorization Timeframes for Completion Timeframes for Completion

2 2 When An Injured Worker Presents with a Form CA- 16 NO authorization is needed for NO authorization is needed for  Office Visits and Consultations  Labs  Hospital services (including inpatient)  X-rays (including MRI and CT scan)  Physical therapy  Emergency services (including surgery) Please DO NOT Call ACS for authorizations if you have a CA-16 – The CA-16 IS the authorization Please DO NOT Call ACS for authorizations if you have a CA-16 – The CA-16 IS the authorization

3 3 When An Injured Worker Presents with a Form CA- 16 The CA-16 DOES NOT cover The CA-16 DOES NOT cover  Non-Emergency Surgery  Elective Surgery  Home Exercise Equipment, Whirlpools, or Mattresses  Spa/Gym Membership  Work Hardening Programs Authorization requests must be submitted for these Authorization requests must be submitted for these

4 4 What requires authorization? Whenever you treat a DOL employee, use website (http://owcp.dol.acs-inc.com) to determine if the procedure requires authorization Whenever you treat a DOL employee, use website (http://owcp.dol.acs-inc.com) to determine if the procedure requires authorization If you don’t have web access, call to speak with a representative or call the Interactive Voice Response (IVR) system at to determine if authorization is needed If you don’t have web access, call to speak with a representative or call the Interactive Voice Response (IVR) system at to determine if authorization is needed Certain procedures require prior authorization – for example surgery, physical therapy, occupational therapy, and some DME. Certain procedures require prior authorization – for example surgery, physical therapy, occupational therapy, and some DME.

5 5 Authorization Levels LEVEL 1: Procedures do not require authorization (for example, Office Visits, MRIs, Routine Diagnostic Tests). LEVEL 1: Procedures do not require authorization (for example, Office Visits, MRIs, Routine Diagnostic Tests). LEVEL 2: Procedures can be authorized by ACS – often over the phone with ACS. LEVEL 2: Procedures can be authorized by ACS – often over the phone with ACS. LEVEL 3/4: Procedures require authorization by a Claims Examiner but initiated via fax from Provider to ACS. LEVEL 3/4: Procedures require authorization by a Claims Examiner but initiated via fax from Provider to ACS. LEVEL 5: This is covered if total expenditure limits are not exceeded and on closed cases if the date of service is prior to the case closure date. LEVEL 5: This is covered if total expenditure limits are not exceeded and on closed cases if the date of service is prior to the case closure date.

6 6 How to Submit an Auth Request Online at Online at Fax Completed Authorization Request Template to – faxes in other formats will be returned and not processed. Fax Completed Authorization Request Template to – faxes in other formats will be returned and not processed. Mail Authorization Request to: Mail Authorization Request to:  P.O. Box 8300  London, KY

7 7 Authorization Request Templates Available in pdf format at Click on Forms and Links Select FECA

8 8 Info Required for Authorization Requests Claimant name Claimant name Claimant case number Claimant case number CPT or HCPCS code(s) CPT or HCPCS code(s) Specific body part to be treated Specific body part to be treated Requested date of service Requested date of service Appropriate supporting documentation Appropriate supporting documentation Provider name and Provider Number/ID Provider name and Provider Number/ID

9 9 Info Required for Physical Therapy and Occupational Therapy Authorization Requests Claimant name Claimant name Claimant Case number Claimant Case number Requested CPT code(s) Requested CPT code(s) Specific body part to be treated Specific body part to be treated Prescription from attending physician Prescription from attending physician Treatment Plan Treatment Plan Frequency and Duration of Services Frequency and Duration of Services Provider name and Provider Number/ID Provider name and Provider Number/ID

10 10 Info Required for DME Authorization Requests Claimant name Claimant name Claimant case number Claimant case number CPT or HCPCS code(s) CPT or HCPCS code(s) Prescription from attending physician Prescription from attending physician Duration of services Duration of services Rental or purchase price for each item Rental or purchase price for each item Appropriate supporting documentation Appropriate supporting documentation Provider name and Provider Number/ID Provider name and Provider Number/ID

11 11 Authorization Requests Will Be Returned if… The case is closed The case is closed The claimant cannot be found The claimant cannot be found The date of injury is missing for claimant with multiple cases The date of injury is missing for claimant with multiple cases We are unable to determine what service is being requested We are unable to determine what service is being requested Any of the following are missing:  Prescription, when required  Rental or Purchase Price, when required  Frequency and Duration

12 12 Timeframes for Completion Within 3 business days, the authorization will be in the system, forwarded to claims examiner for review, or returned Within 3 business days, the authorization will be in the system, forwarded to claims examiner for review, or returned All spinal surgery and many other surgery authorizations require District Medical Advisor (DMA) review – anticipate 30 days All spinal surgery and many other surgery authorizations require District Medical Advisor (DMA) review – anticipate 30 days In some instances, additional development of the claim by the Claims Examiner is needed to approve or deny an authorization request. Case complexity, claimant responsiveness, Employing Agency responsiveness, Provider responsiveness, and other factors impact the timeline for authorization. In some instances, additional development of the claim by the Claims Examiner is needed to approve or deny an authorization request. Case complexity, claimant responsiveness, Employing Agency responsiveness, Provider responsiveness, and other factors impact the timeline for authorization.

13 13 Notification of Authorization Status If the authorization is approved, the requesting provider receives a letter in the mail. If the authorization is approved, the requesting provider receives a letter in the mail. If the authorization can not be approved, the requesting provider receives a letter in the mail. If the authorization can not be approved, the requesting provider receives a letter in the mail. If the authorization can not be approved at this time because further development by claims examiner is needed, the requesting provider receives a letter in the mail. If the authorization can not be approved at this time because further development by claims examiner is needed, the requesting provider receives a letter in the mail. If the authorization is formally denied, the injured worker receives letter in the mail. If the authorization is formally denied, the injured worker receives letter in the mail. Use to check authorization status Use to check authorization status

14 14 Further Development Letter

15 15 Authorization Letter

16 16 A Final Note About Authorizations… Submitting a request does not guarantee approval. Submitting a request does not guarantee approval. Bills for authorized services must meet specifications and requirements to be processed and paid. Bills for authorized services must meet specifications and requirements to be processed and paid.


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