When Does a Doctor Need Advance Authorization

Woman Injured at Work

Throughout your workers’ compensation case, it is imperative to have a good understanding of where your case stands in addition to how your medical procedures are being handled. During this time you are likely to face an abundant amount of medical care and treatments, some of which may require a pre-authorization.

When Must a Physician Request Authorization in Advance

As of March 13, 2007, insurance carriers were given authorization to require the injured employee to obtain x-rays, CT scans, MRIs or other diagnostic tests from the provider or facility within that contracted network. Once the insurance carrier notifies the individual of this requirement, it is then up to the individual to receive such testing from the network provider or facility. The exception to this is emergency situations when there isn’t a location within a reasonable distance from the individual. By law, physicians are required to request prior authorization for situations such as specialist consultations, surgical procedures, physiotherapeutic procedures, x-rays or special diagnostic laboratory testing which would amount to more than $1,000. As of July 11, 2007, special services and procedures must cost $1,000 or more before requiring a prior authorization. This, in turn, means that many of the procedures insurance carriers are allowed to make a requirement of the individual may also require pre-authorization.

Can a Doctor Proceed with Treatment if Authorization is Withheld

In certain circumstances where authorization has been withheld without reason for 30 days or longer, doctors may proceed to render services that are required for the individual’s health and welfare. In situations where the authorization is for a diagnostic test and the insurance carrier has contracted with network requiring individuals to utilize the network, the test must be from a provider or facility within the network. During your workers’ comp case, you may run into situations that are difficult to navigate on your own which makes it imperative to work with an attorney who is dedicated to seeing you get the treatment you deserve and back on the road to recovery. To receive help through every step of your case, contact the attorneys of Erwin, McCane & Daly; allow our experts to put your mind at ease!