Ariz. Admin. Code § R20-5-1311 - Administrative Review by Commission

A. Absent further action of the Commission under R20-5-1301(C), administrative review under this Article is available for requests for medical treatment or services related to all body parts and conditions.

B. A request for administrative review shall be in writing using Section V (Provider or Employee Request for Administrative Peer Review) of the Medical Treatment Preauthorization Form approved by the Commission under R20-5-106(A)(12). A request for administrative review must attach copies of relevant medical information or records and copies of all documentation related to the payer's decision or non-response. A request for administrative review must be submitted to the Commission by mail, electronically or by fax.

1. Identifying information of the injured employee and claim, including the injured employee's name, address, commission claim number, and date of injury;

2. Diagnosis and ICD code;

3. Identifying information of the employer, insurance carrier or TPA ;

4. Identifying information of the provider;

5. Information pertaining to request for treatment, such as the justification for treatment, applicable treatment guideline and, if applicable, the payer's denial of treatment;

6. Copies of relevant medical information or records;

7. Copies of documentation related to the payer's decision or non-response; and

8. Whether the request for medical treatment or services involves a request for urgent care or a life-threatening condition.

C. Upon receipt of a request for administrative review, the Commission shall determine whether the administrative review is available under this Article.

1. If administrative review is not available, then no later than three business days after receiving a request for administrative review, the Commission shall send notice to the injured employee and payer that administrative review is not available.

2. If administrative review is available, then no later than three business days after receiving the request, the Commission shall send notice to the payer that a request for administrative review has been received and provide information on how to participate in the process.

D. The administrative review conducted under this Section shall apply the guidelines as described in this Article and include a peer review performed by an individual meeting the requirements of subsection (I). The peer review shall consist of a records review and, when possible as described in subsection (I)(5), a conversation between the provider and individual conducting the peer review.

E. The Commission may enter into an agreement with one or more contractors, who shall be URAC accredited, to provide the review described in subsection (D).

F. The payer shall pay for the costs of the peer review conducted by the contractor.

G. To assist in its review, the Commission or its contractor may request or receive additional information and documentation from the provider, injured employee or payer, who shall cooperate and provide the Commission or its contractor with any necessary medical information, including information pertaining to the payer's decision.

H. Before the Commission or its contractor issues a determination denying the request for treatment or services, a good faith effort shall be made to conduct a peer review with the provider requesting authorization to perform the treatment or services.

I. The individual conducting the peer review shall:

1. Hold an active, unrestricted license or certification to practice medicine or a health profession and be involved in the active practice of medicine or a health profession during the five preceding years. For purposes of this subsection, "active practice" means performing patient care for a minimum of eight hours per week in one of the five preceding years;

2. Be licensed in Arizona, unless the Commission or its contractor is unable to find such an individual, in which case the peer review may be conducted by an individual who is licensed in another state of the United States and who meets the other requirements of this subsection;

3. For a review of a request from an allopathic or osteopathic physician, nurse practitioner, physician assistant, or other mid-level provider, hold a current certification from the American Board of Medical Specialties or the American Osteopathic Association in the area or areas appropriate to the condition, procedure or treatment under review;

4. Be in the same profession and the same specialty or subspecialty as typically performs or prescribes the medical procedure or treatment requested; and

5. Make a good faith effort to contact the provider requesting the preauthorization. This good faith effort shall include making telephone contact during the provider's normal business hours and offering to schedule the peer review at a time convenient for the provider.

J. A provider may bill the payer for time spent participating in a peer review under this Section.

K. The Commission or its contractor shall issue a written determination of its administrative review that contains the name and title of the person that performed the administrative review, and includes the following information:

1. Whether the request for treatment or services is authorized or denied, in whole or in part;

2. The information reviewed;

3. The principle reason for the decision; and

4. The clinical basis and rationale for the decision.

L. An interested party dissatisfied with the administrative review determination may request that the dispute be referred to the Commission's Administrative Law Judge Division for hearing. This request for hearing shall:

1. Be in writing;

2. Filed no later than 10 business days after the administrative review determination is issued; and

3. State whether the party requests to participate in the Fast Track ALJ Dispute Resolution Program by stipulation, or declines to participate in the Fast Track ALJ Dispute Resolution Program.

M. If a timely request for hearing is filed, the administrative review determination is deemed null and void and shall serve no evidentiary purpose.

N. The information provided by the parties under this Section and the determination issued by the Commission shall become a part of the Commission claims file for the injured employee.

Notes

Ariz. Admin. Code § R20-5-1311

Adopted by final rulemaking at 22 A.A.R. 1730, effective 10/1/2016. Amended by final rulemaking at 24 A.A.R. 2069, effective 10/1/2018.