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UR Medication
#6
(10-29-2018, 01:15 PM)kibby Wrote:
(10-29-2018, 12:50 PM)1171 Wrote: California UR is triggered either by prospective request or retrospective notice.

From the DWC links:
https://www.dir.ca.gov/dwc/MTUS/MTUS-Tex...ations.pdf

There is no list; whether a physician will treat under lien is generally on a case by case decision. Maybe comp attys in your current state know who might be likely to treat a litigated out of state comp claim.

As the costs of treatment has escalated, out of state care for comp is disappearing fast.
Yeah no kidding. It costs them 800 dollars a month just in transportation alone to send me to this doctor. After doctor fees, hotel etc etc it costs them 1600 dollars. Throw in the UR that's 2k Big Grin

The links 1171 provided explains UR well.

There could be many reasons why your medications are being denied. When you write denied do you mean the pharmacy does just not get approval to refill it or do you get a UR denial in the mail? Sometimes the pharmacy needs to run it a few times, especially if it is CVS.

If your doctor is not requesting your medication on an RFA form the adjuster can ignore the request.

If your claim is denied it will most likely be filled.

There are reasons to get a request again before the 12 month period. A change of condition or material facts known. This could be an increase in pain for example or new facts known like you got an MRI that shows material facts not previously known OR even if the MRI you had previously but the information was not previously provided to UR. Your doctor would need to check off the box on the RFA that states change of condition or material facts known. He should also explain the change.

If your doctor is not submitting medical treatment guidelines for the body part you have that coincides with his request, MTUS, chronic pain, ODG or ACOEM it may be difficult to get approvals through UR. He can also go outside of those guidelines if your condition or request does not fall within those guidelines.

It can be difficult to find a doctor to treat on a lien, especially now with the new rules. He can request a consult with a spine surgeon and send it to UR. However it sounds like you are having difficulties having him do that.

So to answer your question usually an RFA form from your doctor triggers UR, but not always. Claims adjuster can approve the request instead of sending to UR and also you may have been approved previously for a number of refills. Due to this you should ask the pharmacy to please run it through again if it is denied. Sometimes it takes time for the adjuster to approve or for it to be sent to UR. Some doctors do not even turn in the RFA form for several weeks. There are several reasons why you may be having difficulties.

Most companies have a internal UR appeals process after it is denied (not IMR). read the entire UR denial to see if this is an option. It is also important to read the reasons for the denial. Was it due to lack of information?

Good luck to you.
I am not an attorney.Anything I write should not be considered legal advice.I am writing from my own personal experiences,which is not from any sort of legal background. You should consult with an attorney over legal issues. In California, if you cannot get an attorney you can consult with an I&A officer.
 
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Messages In This Thread
UR Medication - kibby - 10-28-2018, 11:47 AM
RE: UR Medication - 1171 - 10-28-2018, 01:56 PM
RE: UR Medication - kibby - 10-29-2018, 12:07 PM
RE: UR Medication - 1171 - 10-29-2018, 12:50 PM
RE: UR Medication - kibby - 10-29-2018, 01:15 PM
RE: UR Medication - California_Help - 10-29-2018, 09:16 PM

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