CSPMR Practice Tip
"Request for Authorization for Medical Treatment (DWC Form RFA)"
For the last two or three years, the Division of Workers’ Compensation has wanted to implement a standardized form to be used by physicians when requesting authorization for treatment. The Division determined that physician requests submitted as “recommendations” or “suggested therapies” were not sufficient. Provisions of SB 863 mandate the use of such a form. It is called the “Request for Authorization for Medical Treatment,” or “DWC Form RFA.”
As part of the Utilization Review (UR) and Independent Medical Review (IMR) provisions of Senate Bill 863, beginning January 1, 2013, medical providers MUST USE a new, “Request for Authorization” form to request prior authorization of medical treatment services. The new RFA must be used on all requests regardless of the date of injury.
The RFA is a separate document that is filed along with either the Doctor’s First Report of Injury (DFR) or a PR-2 or a narrative report substantiating the request. No longer can physicians hide requests for prior authorization within other documents. You can download a copy of the most recent draft of this form by going to the CSPM&R homepage (www.CSPMR.net) or by clicking here.
The new RFA form will provide its greatest medical and administrative benefit when it is completed and submitted with as great a detail as possible. Members should assume nothing is understood by the recipient and that each RFA may eventually be provided to an Independent Medical Review physician as the primary basis for the IMR paper review.
This “Practice Tip” contains links to some specific regulations or Labor Codes as indicated. For more detail and a thorough understanding, click here for a copy of the entire text of the last draft of the new IMR regulations.
1) Read and fully understand this “Practice Tip” and the printed instructions for completing the RFA found on the back of the form.
2) A RFA is required to initiate the UR process. A RFA must accompany either a Doctor’s First Report of Injury (DFR) OR a PR-2 OR a narrative report substantiating the request whenever prior authorization of a treatment service is being requested.
3) The first check box indicates if your request is for an expedited review. Expedited review is defined in §9792.6.1:
§9792.6.1 (g). “Expedited review” means utilization review conducted when the injured worker's condition is such that the injured worker faces an imminent and serious threat to his or her health, including, but not limited to, the potential loss of life, limb, or other major bodily function, or the normal timeframe for the decision-making process would be detrimental to the injured worker's life or health or could jeopardize the injured worker's permanent ability to regain maximum function. (emph. added)
NOTE: Expedited reviews require an accelerated response by the claims administrator as defined in existing CCR Title 8, §9792.9 (f) and new CCR Title 8, §9792.9.1 (c)(3)(A). Click on the section titles above to be connected to the text of these sections. It is up to the requesting physician and staff to track compliance with these timeframes.
4) The second check box, labeled “confirmation of an oral request,” implies the requesting physician has obtained verbal (phone) approval of a request for authorization from the claims administrator prior to submitting the RFA. Such phone calls are billable events using either CPT Code 99371 (simple or brief), 99372 (intermediate) or 99373 (complex or lengthy). Click here to access the OMFS page describing use of and reimbursement for these codes.
5) Be sure to check both boxes when both situations are present (i.e., an oral request for expedited treatment).
6) The “Routing Instructions” are incorrect. The new regulation (CCR Title 8, Section 9792.6.1 (t)) clearly states that the RFA can be also be emailed. NOTE: CCR Title 8, Section 9792.9.1 (a) (1) defines when an RFA is considered received, as follows (emph. added):
“(1) For purposes of this section, the DWC Form RFA shall be deemed to have been received by the claims administrator or its utilization review organization by facsimile or by electronic mail on the date the form was received if the receiving facsimile or electronic mail address electronically date stamps the transmission when received. If there is no electronically stamped date recorded, then the date the form was transmitted shall be deemed to be the date the form was received by the claims administrator or the claims administrator’s utilization review organization. A DWC Form RFA transmitted by facsimile after 5:30 PM Pacific Time shall be deemed to have been received by the claims administrator on the following business day, except in the case of an expedited or concurrent review. The copy of the DWC Form RFA or the cover sheet accompanying the form transmitted by a facsimile transmission or by electronic mail shall bear a notation of the date, time and place of transmission and the facsimile telephone number or the electronic mail address to which the form was transmitted or the form shall be accompanied by an unsigned copy of the affidavit or certificate of transmission, or by a fax or electronic mail transmission report, which shall display either the facsimile telephone number to which the form was transmitted. The requesting physician must indicate if there is the need for an expedited review on the DWC Form RFA.”
7) Use of Form RFA does not eliminate the need for a proof of service when mailing via the US Postal Service.
8) Instructions found on the back of the Form state that the RFA must contain “all the information needed to substantiate the request for authorization.”
a. The chart provided for the “requested treatment” seems to imply that a single diagnosis, ICD-9, procedure/CPT code and supporting information is to be provided with each RFA. That is not the case. An RFA can request authorization for multiple treatment modalities, diagnostic tests, DME, prescription medications, etc.
i. Attach copies of the chart to the first page of the RFA, when multiple diagnoses are present and/or multiple procedure codes are being requested. Provide a chart for each and every diagnosis and/or requested procedure. Be careful to provide all of the “other information” and especially medical “evidence” for each.
b. When applicable, the chart should clearly identify all non-physician providers of goods or services that the requesting physician needs to deliver or otherwise requires be involved with providing the requesting treatment. Non-physician providers include, but may not be limited to, surgery facilities, diagnostic testing facilities, physical medicine provider(s), DME, prescription medications, or other medically necessary therapy.
i. Complete contact information should be provided for all non-physician providers because CCR Title 8, §9792.9 (c) (4) & (5), (h)(2), and in several other references, requires that the claims administrator provide copies to them of any response regarding delays, denials or modifications or notices of anyWCAB hearings concerning the request(s). Please click here to refer to the new IMR regulations to find the sections mentioned above.
c. It is important to understand that the fifth bullet point erroneously states:
“For requested medical treatment that is: (a) inconsistent with the Medical Treatment Utilization Schedule (MTUS) found at California Code of Regulations, title 8, section 9792.20, et seq.; or (b) for a condition or injury not addressed by the MTUS, (the requesting physician must) include scientifically based evidence published in peer-reviewed, nationally recognized journals to recommend specific medical treatment or diagnostic services (emph. added).
While “published, peer reviewed, nationally recognized journals” are best, they are not the only “evidence” that is allowed. CCR Title 8, § 9792.10.1 (a) (4) states:
“Medically necessary” and “medical necessity” mean medical treatment that is reasonably required to cure or relieve the employee of the effects of their injury and based on the following standards, which shall be applied in the order listed, allowing reliance on a lower ranked standard only if every higher ranked standard is inapplicable to the employee’s medical condition:
(A) The guidelines adopted by the administrative director pursuant to Labor Code section 5307.27. (MTUS)
(B) Peer-reviewed scientific and medical evidence regarding the effectiveness of the disputed service.
(C) Nationally recognized professional standards.
(D) Expert opinion.
(E) Generally accepted standards of medical practice.
(F) Treatments that are likely to provide a benefit to a patient for conditions for which other treatments are not clinically efficacious.”
9) In addition to the new regulation § 9792.10.1 (a), existing regulation § 9792.25 defines the MTUS presumption of correctness and defines the DWC’s “Burden of Proof and Strength of Evidence” scale that is to be used in the UR process to compare “evidence” submitted with a written request for authorization when the requested treatment is not covered by the MTUS or “other scientifically and evidence-based medical treatment guidelines that are nationally recognized by the medical community.” This regulation, authorized by Labor Code Sections 5307.27 and 4604.5 has been operative since July 18, 2009. This regulation is extremely thorough and can be found on the DWC website at: http://www.dir.ca.gov/t8/9792_25.html.
10) The final paragraph found at the bottom of the Instructions, is addressed to the claim administrator, not the physician submitting a RFA. The claims administrator does not need to notify the physician of its approval using the section provided at the bottom of the RFA. They can choose to “utilize other means of written notification.” Nevertheless, existing CCR Title 8, §9792.9 (k) and new CCR Title 8, §9792.9.1 (e) outlines what must be included in the written notification of modification, delay or denial. Click on the section titles above to access the text of the sections. The physician’s staff must be alert for such alternatives and assure that the contents of the notice are complete according to the regulations.