Dwc_Rules

* Added form: “Notice of non-cert due to insufficient information” – If the nurse previously requested additional info and did not receive it and the peer reviewer denied the request due to lack of information, you will see this notice of non-cert instead of the standard non-cert. There is specific language added at the end of the peer review report and your notice of non-cert “Reconsideration of this request will be provided if additional information as requested is received”. * Appeals process renamed to “Injured worker dispute process” – verbiage changed throughout form from “appeals” to “dispute” * General Cert to Vendor – will state what was requested AND what was authorized. If the request was sent to peer review and then authorized, you will see the dates that this occurred in the cert. This cert also used to have the following statement “Under Labor Code Sec 4616 we reserve the right to use our MPN Providers for all recommended services.” This has been removed as according to the DWC, we cannot make that statement –* has to be the one to make that statement. For UR purposes, we can only make decisions based on medical necessity. * General non-cert to vendor – what was non-certified, peer reviewer information and date of peer review determination * Request for additional info - The statement “if the requested information is not provided then the request will be delayed" has been changed from delayed to “denied”. The nurse must also be specific as to what information they need from the provider in order to make a decision. * Notice of certification - will state what was requested AND what was authorized. If the request was sent to peer review and then authorized, you will also see peer reviewer information and dates that the notices were sent. * Notice of non-cert/modification – Again, dates will be included in this notice. Also, the last sentence used to read "See attached injured workers dispute process for information on appealing this decision”. Now reads "See attached injured workers dispute process for information on disputing this decision” * Request for peer review – removed the word “expert” from the statement “We need your expert review and opinion regarding this request.” The statement now reads “We need your review and opinion regarding this request.” * Remember when sending notices: * Authorizations must be sent to the requesting provider and any ancillary provider requesting to perform the service. (to ancillary provider, only include information that the request is certified, non-certified or modified. No other information should be included such as medical information about the claimant) * Modifications/Notice of non-certs must be sent to requesting physician, claimant, attorneys, and any ancillary provider requesting to perform the service (to ancillary provider, only include information that the request is certified, non-certified or modified. No other information should be included such as medical information about the claimant) * Retro-certs: This is the only authorization that needs to be send to the provider AND copied to the claimant and their attorneys