Ariz. Admin. Code § 20-5-1309
Current through Register Vol. 30, No. 50, December 13, 2024
Section R20-5-1309 - Payer Decision on Request for PreauthorizationA. Except as provided in subsections (C) or (D), a payer shall communicate to the provider its decision on a request for preau-thorization no later than 7 business days after the request is received. The decision shall be issued in writing using Section II (Payer Decision on Request for Preauthorization) of the Medical Treatment Preauthorization Form approved by the Commission under R20-5-106(A)(12). A payer shall attach to the decision a statement of what has been authorized, including, if applicable, a partial authorization, and, if the request for preauthorization is denied, in whole or in part, a statement of explanation that includes the medical reason supporting the payer's decision. For purposes of this Section, the 7 business days begin to run the day after the payer receives the request.B. If a payer fails to communicate to a provider its decision on request for preauthorization within 7 business days, then the payer's failure to take action is deemed a "no response" and the provider or injured employee may submit a request for administrative review directly to the Commission as provided in R20-5-1311.C. If a payer receives a request for preauthorization not submitted on Section I (Provider Request for Preauthorization) of the Medical Treatment Preauthorization Form approved by the Commission under R20-5-106(A)(12) or an incomplete request for preauthorization using Section I (Provider Request for Preauthorization) of the Medical Treatment Preauthorization Form approved by the Commission under R20-5-106(A)(12), the payer shall: 1. No later than 7 business days after the request is received and identified, act on the request for preauthorization pursuant to subsection (A); or2. No later than 7 business days after the request is received and identified, notify the provider in writing that the request for pre-authorization is incomplete or, if applicable, that a request for preauthorization must be submitted on Section I (Provider Request for Preauthorization) of the Medical Treatment Preauthorization Form approved by the Commission under R20-5-106(A)(12).D. If, no later than 7 business days after a request for preauthorization has been received, a payer provides written notice to the provider that an IME has been requested under R20-5-114 using Section II (Payer Decision on Request for Preauthorization) of the Medical Treatment Preauthorization Form approved by the Commission under R20-5-106(A)(12), then the payer's decision on a request for preauthorization shall be issued no later than 7 business days after the final IME report has been received by the payer. The payer shall provide a copy of the final IME report to the provider upon receipt of the IME report.E. Unless the payer decision was supported by an IME or otherwise falls within subsection R20-5-1304(B), an injured employee or provider may seek reconsideration of a payer decision by submitting a written request to the payer (or review organization identified by the payer) using Section III (Provider or Employee Request for Reconsideration) of the Medical Treatment Preauthorization Form approved by the Commission under R20-5-106(A)(12). A provider shall attach to a request for reconsideration a statement of the specific reasons and justifications to support the request. If not previously provided, the injured employee or provider shall attach supporting medical documentation with the request for reconsideration.F. An injured employee may seek review of a payer decision that is supported by an IME by requesting an investigation under A.R.S. § 23-1061(J).G. Unless the decision was supported by an IME, an injured employee or provider may seek review of a payer decision issued under R20-5-1304(B) by requesting administrative review by the Commission as provided in R20-5-1311.
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H. A payer shall provide a copy of its written decision to deny treatment or services to the injured employee or, if represented, to the injured employee's authorized representative.Ariz. Admin. Code § R20-5-1309
Adopted by final rulemaking at 22 A.A.R. 1730, effective 10/1/2016. Amended by final rulemaking at 24 A.A.R. 2069, effective 10/1/2018.