Treating physicians are required to submit a complete and compliant Request for Authorization (RFA) for treatment.
There are three RFA types: concurrent, prospective, and retrospective.
Regulation 9792.6.1 defines a retrospective review as any utilization review conducted after medical services have been provided and for which approval has not already been given.
Retrospective Required Timelines
Per regulation 9792.9.1(c)(5), a utilization review decision for a retrospective RFA is due within 30 calendar days of receipt of “the request for authorization and medical information that is reasonably necessary to make the determination.” For the retrospective RFA, the regulation does not specifically require a completed DWC Form RFA.
Regulation 9792.9.1(d)(3) requires the claims administrator to communicate the approve decision to the requesting physician who provided the medical services and to the patient who received the medical services and to their attorney or designee if applicable. The approve decision is due within 30 days of receipt of the RFA.
Regulation 9792.9.1(e)(4) requires the claims administrator to send a written decision to modify or deny the RFA recommended treatment to the requesting physician who provided the medical services and to the patient who received the medical services and to their attorney or designee, if applicable. The written decision must be sent within 30 days of receipt of the RFA.
Retrospective Review Penalty
If a claims administrator fails to respond to a retrospective RFA, regulation 9792.12(a) mandates that the mandatory penalty is $500 for each failure.
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
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