Medical Authorization Tips for Providers - Overview • When An Injured Worker Presents with a Form CA- 16 • Services that require authorization • Submitting an authorization request • Information required to process an authorization • Timeframes for Completion
When An Injured Worker Presents with a Form CA- 16 • 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
When An Injured Worker Presents with a Form CA- 16 • 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
What 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 850-558-1818 to speak with a representative or call the Interactive Voice Response (IVR) system at 866-335-8319 to determine if authorization is needed • Certain procedures require prior authorization – for example surgery, physical therapy, occupational therapy, and some DME.
Authorization Levels • 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 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.
How to Submit an Auth Request • Online at http://owcp.dol.acs-inc.com • Fax Completed Authorization Request Template to 800-215-4901 – faxes in other formats will be returned and not processed. • Mail Authorization Request to: • P.O. Box 8300 • London, KY 40742-8300
Authorization Request Templates Available in pdf format at http://owcp.dol.acs-inc.com • Click on Forms and Links • Select FECA
Info Required for Authorization Requests • Claimant name • Claimant case number • CPT or HCPCS code(s) • Specific body part to be treated • Requested date of service • Appropriate supporting documentation • Provider name and Provider Number/ID
Info Required for Physical Therapy and Occupational Therapy Authorization Requests • Claimant name • Claimant Case number • Requested CPT code(s) • Specific body part to be treated • Prescription from attending physician • Treatment Plan • Frequency and Duration of Services • Provider name and Provider Number/ID
Info Required for DME Authorization Requests • Claimant name • Claimant case number • CPT or HCPCS code(s) • Prescription from attending physician • Duration of services • Rental or purchase price for each item • Appropriate supporting documentation • Provider name and Provider Number/ID
The case is closed The claimant cannot be found The date of injury is missing for claimant with multiple cases 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 Authorization Requests Will Be Returned if…
Timeframes for Completion • 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 • 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.
Notification of Authorization Status • 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 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. • Use http://owcp.dol.acs-inc.com to check authorization status
A Final Note About Authorizations… • Submitting a request does not guarantee approval. • Bills for authorized services must meet specifications and requirements to be processed and paid.