Medical Provider

Prior Authorization

• When to request prior authorization Rule 16-9(A)

• Approval to be in writing Rule 16-9(G)

• Contest of request by payer Rule 16-9(F)

• Contest of request by payer Rule 16-10

• Contest for non-medical reasons Rule 16-10(A)

• Contest timeline (7 days) Rule 16-10(A)&(B)

• Contest for medical reasons Rule 16-10(B)

• Delay Rule 16-10(F)

• Disputes Rule 16-10(C)

• Timely reply to request Rule 16-10(E)

• Notification of request for hearing Rule 16-10(E)(2)

• Unreasonable delay Rule 16-10(F)

• Explain medical necessity to complete request to Rule 16-9(E)

• Payer to respond in 7 days Rule 16-9(B)

• Payer to inform worker and provider of requirements for prior authorization Rule 16-9(C)&(D)

• Lack of authorization does not warrant denial of payment Rule 16-9(H)

• Unreasonable delay or deny Rule 16-10(F)

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