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>PREAUTHORIZATION
PEER REVIEW
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View a summary of the PREAUTHORIZATION
REQUIREMENTS in AWCC RULE 30

Systemedic's Preauthorization Services
We offer the distinct advantage of locally-based and experienced RN specialists. Using nationally recognized review criteria, we address the following:

• Treatment setting (inpatient vs. outpatient)

• Appropriateness of medical procedure

• Length of stay

• Need for physician review and opinion

We use specialty-matched physician level review to determine the appropriateness of procedures/admissions that cannot be authorized at the RN level.

Value-added services:

• Provide medical records and clinical summary to document claim file and clarify extent of injury

• Steer to PPO facility for MCO contract customers

• Integrate preauthorization data with our medical bill review division as an indispensable aid in auditing related charges

• Assess of need for case management services

Although preauthorization review does not address injury relatedness of treatment, the information and medical records obtained during the review process often help clarify claims decisions regarding compensability.

Guidelines for determining if preauthorization is needed
The following require preauthorization:

• Inpatient care (non-emergency)

• Transfers between facilities

• Outpatient facility services exceeding $1,000 billed
  by a provider for a single date of service, including:

  • Outpatient surgeries

  • Magnetic Resonance Imaging (MRI)

  • MR Arthrograms (MRI after arthrogram)

  • Myelograms

  • Epidural Steroid Injections (ESI)

The following do not require preauthorization:

• Physical therapy

• Occupational therapy

• Home health visits

• Routine X-rays and lab tests

• Supplies and Durable medical equipment (DME)

The following typically do not require preauthorization; however, Systemedic has review criteria and can provide a review
if requested:
 

For more information, please contact:
Evonne Nusz, Manager, RN, CCM
Phone: 501-227-5553 or 800-822-2680 (ext. 139)
Fax: 501-978-2050

Use this link if you would like to refer a case to Systemedic.

Summary of Rule 30 Preauthorization Requirements Preauthorization is required in Arkansas
The Arkansas Workers' Compensation Commission requires preauthorization for certain procedures. It also should be noted
that the AWCC modified Rule 30 (effective May 15, 2000) expanding mandated preauthorization to include outpatient services. Rules 30 and 33 enable payers to conduct pre-treatment reviews of proposed inpatient and outpatient procedures to determine if the treatment and length of stay are appropriate.

Rule 30, Part 1, Section S states:
"Preauthorization is required for all non emergency hospitalizations, transfers between facilities and outpatient services expected to exceed $1,000 in billed charges for a single date of service by a provider. A denial decision for payment for any type of health care service and/or treatment resulting from a utilization review, as opposed to a determination of whether such a service or treatment is related to a compensable injury, shall only be made by an Arkansas certified private review agent. The Arkansas Department of Health Utilization Review certification number is required upon request. See Arkansas Workers' Compensation Hospital Inpatient Fee Schedule Part III for procedures for requesting preauthorization. Upon emergency admission, notice must be given to the carrier within 24 hours or the next business day."