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Will WC carrier pay for out of state hotel (CA)
(02-02-2018, 09:10 PM)kibby Wrote:
(02-02-2018, 08:59 PM)California_Help Wrote:
(02-02-2018, 08:46 PM)kibby Wrote:
(01-28-2018, 01:57 PM)California_Help Wrote: It would be helpful if you provided the name of medication and condition it is being prescribed for. 

I still think your claims adjuster should have run it through utilization review, unless the request was not sent on and RFA form, is for an injury that is not accepted OR has been previously denied by UR within the last 12 months. (JMO)

Well, now they just denied my Injections I was supposed to go but I had the appointment rescheduled due to another dr appointment. Good thing or else they would have been on the hook. They sent out the denial on the day I was supposed to have them. Thoracic, neck and lumbar injury is worthless with CIGA

I am surprised your doctor was going to do it without receiving an approval first. They may not have been on the hook if the denial was timely.

If you read your denial there should be two ways you or your doctor can appeal it. First through the internal UR appeal process and then through IMR. There are time limits with both. They should have stated why it was denied and the rational they used to deny it. Just FYI these are not always accurate and many times requests are denied due to lack of information. There are ways to appeal some of these denials (not always). If your doctor is well versed in WC he may know how to appeal this, but there are strict time limits.

He is well versed in GA work Comp, not California...
Also, the denial is filled with inaccuracies, they even called the doctor a psychiatric  even though he is a orthopedic doctor. Would that invalidate their claim? I am filling out the paperwork now

It depends. I think it may be easier to appeal it. I recommend googling the name of the doctor who wrote the UR denial to check his specialty. He may not be located in CA (just FYI). If the UR reviewer is wrong specialty you can appeal it and file a complaint with the medical unit.

As I mentioned before there are 2 ways to appeal UR denials. The first is to do an internal UR appeal (short time frame and it is different for every IC). The second way is through IMR which is 30 days. I have better luck with appealing through internal UR appeals process.

Addressing the reasons for the denial is important. If you need any help finding treatment guidelines let me know (if they are available). Some guidelines were recently changed in CA so I would need to look it up. Guidelines are generally for injured body part. For example if your doctor requested physical therapy I would need to know what is the injury and body parts he is requesting. I do a search under body part and request. With medications this gets complex especially with patients who have multiple injuries and conditions. It is best to have a physicians appeal medications.

I think you may have a better chance if you gave your doctor the treatment guidelines before he does the request since he is not familiar with what is expected in the CA WC system. I can show you how to look for these if you want. This appears to be one of the struggles people have trying to get treatment out of state. It is difficult to get treatment in CA as many CA physicians do not appear to know the guidelines either.(JMO)

Good luck with your appeal.
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.

Messages In This Thread
RE: Will WC carrier pay for out of state hotel (CA) - California_Help - 02-03-2018, 02:25 PM

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