If you need to refer a new preauthorization case, submit a secure preauthorization referral below. If you need immediate assistance, give us a call today.
FOR THE LATEST NEWS
Physician peer review
We coordinate specialty-matched physician peer review to determine aptness of procedures or admissions that do not meet review criteria or guidelines for preauthorization and therefore cannot be authorized at the RN level of review. The peer review is based on the evaluation of medical records and documents an expert opinion of the case. This expert opinion is one of several factors that can be considered in a claims decision regarding eligibility, treatment, or payment by an insurance carrier, TPA, or employer.
Every Case is Unique, RN Coordination to Meet Criteria
Preauthorization for Arkansas workers’ compensation
The Arkansas Workers’ Compensation Commission (AWCC) requires preauthorization for certain procedures. 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
Following the guidelines for preauthorization, only an Arkansas-certified utilization review entity can make a denial decision for payment of any type of healthcare service or treatment resulting from a utilization review.
Guidelines for preauthorization
The following require preauthorization service for workers’ compensation in Arkansas:
- inpatient care (non-emergency)
- transfers between facilities
- outpatient facility services exceeding $1,000 billed by a provider for a single date of service
- most outpatient surgeries
- most MRIs
- MR arthrograms (MRI after arthrogram)
- ESIs (depending on location of service)
The following do not require preauthorization service for workers’ compensation in Arkansas:
- physical therapy
- occupational therapy
- home health visits
- routine x-rays and lab tests
- most injections
- Durable Medical Equipment (DME) and supplies
The following typically do not require preauthorization service for workers’ compensation in Arkansas:
- bone scans
- CT scans
- EMG/NCV studies
However, Systemedic has review criteria and can provide a review if requested.
Ready to Get Started?
Learn how Systemedic can help.