Prior Authorization Denials in Colorado

Dollars & Cents

Now that you know the basics on prior authorization in the Rocky Mountain State, you might be wondering what happens if prior authorization is denied in Colorado. Yet again, Simply Research has you covered, but here's a look at the rules.

Medical Opinion Required

If an ATP requests Prior Authorization and indicates in writing, including reasoning and supporting documentation, that the requested treatment is related to the admitted workers' compensation claim, the Payer cannot deny solely for relatedness without a medical opinion.

The medical review, independent medical examination (IME) report, or report from an ATP that addresses relatedness of the requested treatment to the admitted claim may precede the Prior Authorization request if:

1. The opinion was issued within 365 days prior to the date of the Prior Authorization request; and

2. An admission of liability has not been filed admitting the relatedness of the requested treatment to the admitted claim or a final order has not been entered finding the specific medical condition related to the admitted injury.

If not, the medical review, IME report, or report from the ATP must be subsequent to the prior authorization request.

Reasons for Denial

The Payer may deny a request for Prior Authorization for medical or non- medical reasons. Examples of non-medical reasons include:

+ No WC claim has been filed with the Payer;

+ Compensability has not been established;

+ The Provider is not authorized to treat;

+ The insurance coverage is at issue;

+ Typographic or date errors on the bill;

+ Failure to submit medical documentation; or

+ Unrecognized or improper use of a CPT® code.

If the Payer is denying a request for non-medical reasons, the Payer shall, within 10 days of receipt of the complete request, furnish the requesting ATP and the parties with a written denial that sets forth clear and persuasive reasons for the denial, including citation of appropriate statutes, rules, and/or supporting documents (e.g., a copy of claim denial or a detailed explanation why the requesting Provider is not authorized to treat).

If the Payer is denying a request for medical reasons, the Payer shall, within 10 days of receipt of the complete request:

1. Have all the submitted documentation reviewed by a Physician, who holds a license in the same or similar specialty as would typically manage the medical condition or treatment under review. The Physician performing this review shall be Level I or II Accredited. In addition, clinical Pharmacists (Pharm.D.) may review Prior Authorization requests for medications, and Psychologists may review requests for mental health services, without having received Level I or II Accreditation.

After reviewing all the submitted documentation documentation referenced in the Prior Authorization request that is available to the Payer, the reviewing Physician may call the requesting Provider to expedite the communication and processing of the Prior Authorization request.

The Payer may limit approval of initial treatment to the number or duration specified in the relevant MTG without a medical review.

2. Furnish the requesting ATP and the parties with a written denial that sets forth an explanation of the specific medical reasons for the denial, including the name and professional credentials of the Provider performing the medical review and a copy of the reviewer’s opinion; the specific citation from the MTGs, when applicable; and identification of the information deemed most likely to influence a reconsideration of the denial, when applicable.

Authorization for Payment

Failure of the Payer to timely comply in full with all Prior Authorization requirements shall be deemed authorization for payment of the requested treatment unless the Payer has scheduled an independent medical examination (IME) and notified the requesting Provider of the IME within the time prescribed for responding.

1. The IME must occur within 30 days, or upon first available appointment, of the Prior Authorization request, not to exceed 60 days absent an order extending the deadline.

2. The IME physician must serve all parties concurrently with the report within 20 days of the IME.

3. The Payer shall respond to the Prior Authorization request within 10 days of the receipt of the IME report.

4. If the injured worker does not attend or reschedules the IME, the Payer may deny the Prior Authorization request pending completion of the IME.

5. The IME shall comply with Colorado rules for authorized treating physicians.

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