Ala. Admin. Code r. 480-5-5-.23

Current through Register Vol. 43, No. 1, October 31, 2024

Section 480-5-5-.23 - Appeals Process For Utilization Review Bill Screening, Peer Clinical Review And Denial Or Revocation Of Utilization Review Certificate

(1) Adverse decisions rendered under Rule 480-5-5-.08 or 480-5-5-.10 regarding medical necessity shall be subject to peer review and/or administrative appeal at the request of any party as follows:

(a) Peer Clinical Review

1. All UREs or employers/agents shall have in place an appeal process through Peer Clinical Review (Third Level clinical Review) when an adverse decision is rendered.

2. The Peer Clinical Review (Third Level Clinical Review) process shall be initiated by the provider contacting the RUE or employer/agent by telephone or other immediate means following receipt of the decision to be followed by a written request that shall include medical records and/or data needed to reach a decision.

3. The Peer Clinical Review (Third Level Clinical) request shall be evaluated in accordance with Rule 480-5-5-.07. The reviewer shall make a decision within 30 calendar days, unless an expedited appeal pursuant to Rule 480-5-5-.07 is required.

(i) If the Peer Clinical Review (Third Level Clinical Review) decision is a reversal of noncertification or denial, the admitting physician, hospital or other provider shall be immediately notified via telephone and a follow-up letter or facsimile shall be sent to the physician, hospital or other provider.

(ii) If the Peer Clinical Review (Third Level Review) decision upholds noncertification or denial, the adjudicator shall verbally notify the admitting physician, hospital or other provider and shall immediately submit in writing the denial and case documentation to the requesting party and any other provider involved in the case.

(b) Administrative Appeal

1. Administrative appeals may be requested at the option of any party, by filing a letter of request with the Workers' Compensation Division.

(i) Medical Dispute Resolution

(I) Any adverse determination, resulting from the Peer Clinical Review (Third Level Clinical Review) process, may be submitted to medical dispute resolution at the written request of any party. Notice shall be given to all parties and the dispute may be decided by an Ombudsman after an informal hearing and/or an examination of the record. If the parties agree, the dispute may be presented to an Ombudsman for an alternative dispute resolution hearing through the mediation process. Decisions shall be rendered within 60 days of a hearing.

2. A party to a medical dispute that remains unresolved after a review of medical services has been accomplished pursuant to Code of Ala. 1975, § 25-5-77(i), may petition the circuit court for relief. Medical dispute resolution through mediation in the Ombudsman Program is not a prerequisite to petitioning the circuit court for ruling.

(2) Denial or Revocation of OUR Certificate - Administrative appeal for denial or revocation of a certificate to a qualified Utilization Review Entity as described in Rule 480-5-5-.05 or 480-5-5-.06 shall be submitted in writing to the Workers' Compensation Division.

(a) The appealing party shall request a hearing on the denial or revocation within 30 days of the date of the receipt of the notice to deny or revoke. Failure to mail a request for hearing within the time prescribed shall result in the denial or revocation becoming effective 60 days from the date of mailing of the original notice. In no event shall any denial or revocation become effective prior to the date that a hearing is scheduled.

The Department's written notice shall be by certified or registered mail to the interested parties.

(b) A Hearings Officer shall conduct a hearing on the denial or revocation of a certificate, in accordance with the Department of Industrial Relations Administrative Code, Rule 480-1-4 and render a decision.

(c) Further appeal may be petitioned with the circuit court whose jurisdiction includes the plaintiff's last known business address.

Author: Workers' Compensation Medical Services Board

Ala. Admin. Code r. 480-5-5-.23

New Rule: Filed August 9, 1996; effective September 13, 1996.

Statutory Authority:Code of Ala. 1975, § 25-5-293.