June 11, 2013
by Rebecca Watkins

Do I have to pre-approve a referral or treatment request?

rebecca watkinsWe are seeing more requests to pre-authorize referrals or treatment other than elective surgery.  When no pre-authorization is given, claimants or medical providers file medical disputes with the WCD.  However, the administrative rules do not require such pre-approval.  In a recent dispute before the Medical Review Unit, SBH confronted this issue and successfully convinced the MRU that pre-authorization was not necessary for a referral to a specialist.  The MRU order states: “While the director appreciates [the doctor] would prefer there be authorization for the referral to a knee specialist prior to making the referral, (assumedly for guarantee of payment), authorization by the insurer is not mandated by statute or rule.”  Admin. Order of Dismissal, WCD No. FBB6351 (May 31, 2013).  The MRU dismissed the matter for lack of a ripe dispute and described the proper procedure: referral and treatment, billing, and if the billing is denied, then addressing the dispute through the administrative review process set out in the rules. 

 Although this decision pertained specifically to a referral, the rules only require pre-authorization/rejection for elective surgery. The same result should apply equally to requests for nonsurgical treatment.  When you receive a request for pre-authorization of a service (other than an elective surgery), SBH recommends you advise the medical provider that the requested service does not need pre-authorization.  When you have an elective surgery request, follow OAR 436-010-0250 which triggers a response within seven days. If you have a similar situation and have questions about how to proceed, please give me a call. 

Keep in mind, there are instances where withholding pre-approval simply delays the worker getting treatment.  So, the savvy adjuster should continue to approve clearly appropriate treatment such as when a doctor recommends an MRI due to persistent symptoms.  However, it is also equally important that the adjuster be aware of the right to decline to pre-authorize some services or referrals.  Please contact me with any questions at:  .