053-10 Wyo. Code R. §§ 10-23 - Preauthorization
The Division pursuant to its rules and regulations may issue a determination of preauthorization for an injured worker's nonemergency hospitalization, surgery or other specific medical care WS27-14-601(o) as amended.
(a) Treatment rendered by a
health care provider to a Wyoming Workers' Compensation injured worker for
injuries, will be professionally reviewed and preauthorized on issues of
whether proposed treatment is reasonable, medically necessary and in compliance
with the Division's rules, regulations and treatment guidelines. Such treatment
guidelines shall be predicated on relevant medical literature consistent with
evidence-based medicine, or insurance industry standards or practices, or the
guidance of the Medical Commission, and shall be available upon request. Policy
establishing treatment guidelines shall be available in written format and also
maintained on the Division's internet website located at:
https://dws.wyo.gov/dws-division/workers-compensation/resources-information/preauthorization/
(b) The Division will institute procedures of
preauthorization and utilization review. Policy outlining the description,
medical definitions, and a required list of treatments to be preauthorized
shall be developed, implemented and maintained.
(c) The Division will inform health care
providers when treatment guidelines are expanded or modified, or there are
changes in the Division policy or procedures.
(d) The preauthorization process
(i) Health care provider notification to the
Division
(A) The health care provider must
complete the request for preauthorization review form in writing, in advance of
the injured worker receiving treatment for hospitalizations, surgeries or
health care requiring preauthorization and submit it to the Division by fax,
mail or email. The Provider Request for Preauthorization form can be obtained
from the Division or through the internet at:
https://dws.wyo.gov/dws-division/workers-compensation/resources-information/preauthorization/
(B) Concurrent with submission of the
Provider Request for Preauthorization, the health care provider must supply
relevant clinical information. This will include chart notes that document the
injured worker's history, physical examination findings, diagnostic test
results, treatment plan, and prognosis.
(ii) The Division will make a determination
to authorize or deny treatment as requested per the preauthorization review
form, pursuant to the procedures outlined in W.S. §
27-14-601(k).
(e) The
Administrator or the Administrator's designee will make medical coverage
decisions to ensure quality of care and prompt treatment of injured workers.
Medical coverage policies and procedures will include, but are not limited to,
decision on health care services, hospitalizations, surgical procedures,
medical care, pharmaceuticals, rehabilitative modalities, devices, diagnostic
tests, ambulatory services, and supplies rendered for the purpose of diagnosis,
treatment or prognosis.
Notes
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No prior version found.