|TELEPHONE||501.227.5553 or 800.822.2680|
|TO REFER||Call either of the phone numbers above and tell us you have a new preauthorization case to refer. You will be transferred to an automated questionnaire to give basic information. Shortly after you hang up, a preauthorization specialist will contact you.|
Systemedic offers the distinct advantage of locally based and experienced RN Preauthorization specialists. We use nationally recognized review criteria to address the following:
Physician Peer Review
We use specialty-matched physician peer review to determine appropriateness of procedures or admissions that do not meet review criteria and therefore cannot be authorized at the RN level of review. A peer review, based on a review of the medical records, documents an opinion, one of several factors that can be considered in a claims decision regarding eligibility, treatment, or payment by an insurance carrier, TPA, or employer.
Upon referral, Systemedic’s RN specialist will obtain medical records, recommend and compile questions and issues to be addressed, then coordinate referral to an independent out-of-state Arkansas UR certified review provider. When the results come back, we review them to make sure all pertinent issues were addressed before forwarding to our customers.
Preauthorization Is Required in Arkansas Workers’ Compensation
The Arkansas Workers’ Compensation Commission (AWCC) requires preauthorization for certain procedures (see guidelines at left). Rules 30 and 33 enable payers to conduct pre-treatment reviews of proposed inpatient and, within specific parameters, outpatient procedures to determine if treatment and length of stay are appropriate. Rule 33 further requires a “medical peer review program” as part of the quality assurance program of an AWCC certified MCO.
A denial decision for payment of any type of health care service or treatment resulting from utilization review, as opposed to a determination of whether a service or treatment is related to a compensable injury, can only be made by an Arkansas certified utilization review entity. (Systemedic holds Arkansas UR certification and can meet this requirement for you.) Any non-approval or non-payment decision, based on a peer review opinion, must be documented and sent to the medical provider(s) involved, with the rationale for the decision, and with required notification of appeal rights as detailed in Rules 30 and 33.
Guidelines for Preauthorization
The following require preauthorization:
The following do not require preauthorization:
The following typically do not require preauthorization:
However, Systemedic has review criteria and can provide a review if requested.