When your doctor wants approval for a test, an office visit, surgery, physical therapy, etc., he will submit a written request to the Insurance Company on a Form 1010. The Insurance Company will forward that to their Utilization Review (UR) service provider. UR will review the request for testing, treatment, etc. to determine if medically necessary under the state’s Medical Treatment Guidelines (MTG). UR will then approve or deny the request.
If the request is denied, you can appeal the denial to the state Medical Director, Dr. Picard, using a Form 1009. You must file the Form 1009 within 15 days of the denial. After that, it is too late. You must include the Form 1010 request, the UR denial and supporting medical records with the Form 1009. You don’t have a lot of time to gather this information and get this done.
Dr. Picard will review the request and denial and issue a recommendation. If he grants the appeal, he is recommending approval. Then the insurance company has 45 days to challenge Dr. Picard’s recommendation by filing a Disputed Claim for Compensation (Form 1008) with the Office of Workers’ Compensation. If they don’t, you or your attorney can seek to enforce the recommendation through the Office of Workers’ Compensation by filing a Form 1008. All litigation before the Office of Workers’ Compensation begin with the filing of a Form 1008.
Consult with an experience workers’ compensation attorney if treatment is denied.