A client calls our office stating his work comp doctor has request medical treatment and he hasn't heard from the insurance company. "Why hasn't it been approved," he asks, "It has been several weeks and I have heard nothing."
In order for medical treatment to be approved in California Workers' Compensation, the treating doctor must submit the request for the treatment on the proper form. Specifically, the doctor must fill out a DWC FORM RFA, also known as a "Request For Authorization." Without this form, it is as if the doctor never even requested the treatment. The carrier is under no obligation to authorize the treatment.
In order for the insurance carrier to even consider requested treatment, the medical doctor must submit a request for authorization. Once the insurance carrier has received proper request for authorization on the proper form, they then have between five and 14 days to either authorize or deny the treatment. If they failed to authorize or deny the treatment within the 14 days the treatment is deemed authorized.
In order to better help your attorney, have your treating physician sent a copy of the request for authorization not only to the insurance company but also a second copy to your attorney. This allows your attorney to track the time frame and file for
an expedited hearing should the medical treatment not be authorize a timely fashion.
Should the treatment be authorized, a letter will be sent but both your doctor and yourself know the treatment has been authorized. At this point you can move forward with the treatment.
Should the treatment be denied, a separate letter is also sent outlining the reasons for making a adverse decision. You have 30 days following the denial to appeal the decision of the carrier. Appeals are conducted by the independent medical review also known as IMR.
IMR can make a decision whether to uphold the carrier's denial or to overturn the denial. Should they overturn the denial, the medical treatment will be deemed authorized. However, should IMR uphold the denial of the insurance carrier the treatment is deemed denied for one year or until the applicant's medical condition has had a change of circumstance.
Should you be having any difficulty with getting medical treatment approved, please feel free to contact one of Worker's Compensation law centers offices were one of our attorneys will be more than happy to assist you. We offer a free consultation which we can discuss issues such as medical treatment.