(c) "Concurrent Review"

Summary

Treating physicians are required to submit a complete and compliant Request for Authorization (RFA) for treatment.

DWC FAQ: RFA RequiredThere are three RFA types: concurrent, prospective, and retrospective.

Regulation 9792.6.1 defines a concurrent review as utilization review conducted during an inpatient stay. So that a claims administrator can conduct concurrent utilization review of the requested medical services for service provided during an inpatient stay, a treating physician must submit a concurrent RFA during the inpatient stay.

Concurrent Workers’ Comp RFA

Concurrent Review Required Timeline

Per regulation 9792.9.1(c)(3), a utilization review decision for a concurrent RFA is due within 5 business days after receipt of the completed DWC Form RFA.

Required Timelines for UR Decisions - Concurrent RFA

For a concurrent RFA, the claims administrator must communicate the decision to the requesting physician within 24 hours of making the decision. Regulation 9792.9.1(e)(3) requires the communication of the modify, delay or deny decision to be via telephone, facsimile or email.

Concurrent Review Penalty

If a claims administrator fails to respond to a concurrent RFA, regulation 9792.12(a) mandates that the mandatory penalty is $2,000 for each failure.

Mandatory Penalty for Workers’ Comp Claims Administrators

California Code of Regulations (CCR)

§ 9792.6.1 Utilization Review Standards - Definitions - On or After January 1, 2013
§ 9792.9.1 Utilization Review Standards - Timeframe, Procedures and Notice - On or After January 1, 2013
§ 9792.12 Administrative Penalty Schedule for Labor Code § 4610 Utilization Review Violations

DaisyBill Resources

Daisy News: Your Request for Authorization (RFA) Questions Answered

For more information about California’s workers’ comp electronic billing, watch DaisyBill’s free, information-packed webinars.

Watch Free Webinars

Was this article helpful?

About Us

DaisyBill is a trusted authority on workers’ comp billing. Thousands of work comp professionals attend our webinars and state agencies and professional organizations turn to us for our expertise. We created this blog to help everyone involved in workers’ compensation; sharing news, tips, and data of interest to the community.

Drop us a line with any news you would like us to share or any issue that concerns you.

Read more

Search results for: