Ariz. Admin. Code § 20-5-1310
Current through Register Vol. 30, No. 50, December 13, 2024
Section R20-5-1310 - Payer Reconsideration on Request for PreauthorizationA. Except as provided in subsection (C), a payer shall communicate to the provider its decision on a request for reconsideration no later than 7 business days after the request is received. This decision shall be issued in writing using Section IV (Payer Decision on Request for Reconsideration) 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 subsection, the 7 business days begin to run the day after the payer receives the request for reconsideration.B. If a payer fails to respond to a request for reconsideration within 7 business days, the provider or injured employee may submit a request for administrative review directly to the Commission as provided in R20-5-1311.C. If, no later than 7 business days after a request for reconsideration has been received, a payer provides written notice to the provider that an IME has been requested under R20-5-114 using Section IV (Payer Decision on Request for Reconsideration) 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 reconsideration 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 report.D. Commission Review of Payer Reconsideration Decision: 1. An injured employee or provider may seek review of a payer reconsideration decision by requesting an administrative review by the Commission as provided in R20-5-1311 unless the payer decision was supported by an IME.2. An injured employee may seek review of a payer reconsideration decision that is supported by an IME by requesting an investigation under A.R.S. §; 23-1061(J).
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E. A payer shall provide a copy of its written reconsideration decision to deny treatment or services to the injured employee or, if represented, to the injured employee's authorized representative.Ariz. Admin. Code § R20-5-1310
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.