1) In my last PR-2 report, I requested 2 additional chiropractic visits to quell the effects of the patient’s past exacerbation of pain. This request for authorization was Fax-Served upon the SCIF claims administrator on 03-31-06, and therefore was deemed “received” on 03-31-06. More explicitly, Title 8 CCR section 9792.9(a)(1) states:
“For purposes of this section, the written request for authorization shall be deemed to have been received by the claims administrator by facsimile on the date the request was received if the receiving facsimile electronically date stamps the transmission. If there is no electronically stamped date recorded, then the date the request was transmitted.”
Subsequent to my request for 2 chiropractic visits, the claims administrator has failed to authorized, request additional information, order additional medical testing or evaluation, or request an expert reviewer opinion within the mandated 5 working days.
Title 8 CCR section 9792.9 (b)(1) mandates that the claims administrator must react to the primary treating physician’s (“PTP”) request for authorization “ within 5 working days.” More explicitly, CCR sections 9792.9 (b) and (b)(1) state: “Utilization review process shall meet the following timeframe requirements: (1) Prospective or concurrent decisions shall be made in a timely fashion that is appropriate for the nature of the injured worker's condition, not to exceed five (5) working days from the date of receipt of the written request for authorization."
If appropriate information was include in the PTP’s request for authorization [which it was in this case], and the claims administrator can not made a decision on her own regarding authorization [in this case, the 2 chiropractic treatments], then, per CCR section 9792.9 (g)(2), she “shall immediately notify the requesting physician, the injured worker, and if the injured worker is represented by counsel, the injured worker's attorney in writing, that the claims administrator cannot make a decision within the required timeframe,” which is “5 working days for complete prospective requests for authorization per CCR section 9792.9 (b)(1).
In this case, the claims administrator has clearly blown the mandatory time dead-lines and procedure for requesting “specialized consultation and review of medical information by an expert reviewer,” as defined in CCR section 9792.9 (g)(1) and failed to notify the injured worker, the applicant attorney, and the PTP (me); therefore, the subsequent utilization review opinion dated 04-10-06, and received on 04-12-06, is illegal and non-valid.