Summary

Under specific circumstances, a claims administrator may dispute liability for the medical treatment requested in a Request for Authorization (RFA).

Regulation 9792.6.1 defines dispute liability as an assertion by the claims administrator that a factual, medical, or legal basis exists, other than medical necessity, that precludes compensability on the part of the claims administrator. This can include a not-accepted body part or injury, or not accepted liability for a specific medical treatment.

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

DaisyBill Resources

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

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