Newly implemented rule (04 NCAC 10A.1001 [Rule 1001]) requires, among other things, that you immediately respond to requests for authorization for surgery and hospitalization. Under this rule, you have only seven days to respond or your right to contest that treatment may be waived. NCGS §97-25.3 has always required a prompt response, but this newly enacted rule emphasizes the need to regularly monitor your cases and respond to the inquiries. This rule became effective on November 1, 2014 and also contains additional requirements discussed below.
Pursuant to NCGS §97-25.3, the Commission has adopted a new rule concerning pre-authorization requirements for hospitalization and in-patient and out-patient surgery. These rules became effective November 1, 2014.
In order for a carrier to require pre-authorization for hospitalization or surgery, it must establish a policy meeting certain requirements and post that policy on their company website and with the Industrial Commission. If no policy is posted, the carrier may lose its right to require pre-authorization.
This requirement includes situations where the carrier wants to obtain an IME to determine if the hospitalization or surgery is necessary.
The policy requirements are extensive and provide that specific information be stated in the policy and on the carrier website. More importantly, the rule requires that the carrier respond within seven days of the request for this treatment. The rule also sets out what information must be included in the response.
Failure to respond to the request in a timely manner can result in waiver of the right to contest the medical treatment. The Industrial Commission may grant an extension of time, but it should be requested within seven days of the request for authorization.
This rule also requires that the carrier identify someone with decision making authority who will be available between 8:00 a.m. and 8:00 p.m. to be contacted regarding the pre-authorization request.
