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Board Rule 205 Necessity Of Treatment Disputes Regarding Authorized Treatment

(a)  Reports required by the Board include State Board of Workers’ Compensation Form WC-20(a), or HCFA 1500, HCFC 1450, UB-04 or UB92 and supporting narrative, if any, properly filled out and with supporting itemized hospital charges, discharge summary, and billings from other authorized providers of service and shall be furnished at no charge to the party responsible for payment.  Medical services provided pursuant to the Workers’ Compensation Act are not confidential to the employer/insurer who by law are responsible for the payment of services.  Hospitals and other medical providers who by their own rules require medical releases shall be responsible for obtaining same at the time of treatment.

(b)

(1)  Medical treatment/tests prescribed by an authorized treating physician shall be paid, in accordance with the Act, where the treatment/tests are:

(a)  Related to the on the job injury;

(b)  Reasonably required and appear likely to accomplish any of the following:

(1)  Effect a cure;

(2)  Give relief;

(3)  Restore the employee to suitable employment;

(4)  Establish whether or not the medical condition of the employee is causally related to the compensable accident.

(2)  Advance authorization for the medical treatment or testing of an injured employee is not required by this Chapter as a condition for payment of services rendered.  A Board certified WC/MCO may provide for pre-certification by contract with network providers pursuant to O.C.G.A. § 34-9-201(b)(3).

(3)

(a)  An authorized medical provider may request advance authorization for treatment or testing by completing Sections 1 and 2 of Board Form WC-205 and faxing or emailing same to the insurer/self-insurer. The insurer/self-insurer shall respond by completing Section 3 of the WC-205 within five (5) business days of receipt of this form.  The insurer/self-insurer’s response shall be by facsimile transmission or email to the requesting authorized medical provider.  If the insurer/self-insurer fail to respond to the WC-205  request within the five business day period, the treatment or testing stands pre-approved.

(b)  In the event the insurer/self-insurer furnish an initial written refusal to authorize the requested treatment or testing within the five business day period, then within 21 days of the initial receipt of the WC-205, the insurer/self-insurer shall either:

(a) authorize the requested treatment or testing in writing; or

(b) file with the Board a Form WC-3 controverting the treatment or testing indicating the specific grounds for the controversion.

(c)

(1)  If medical treatment is controverted on the ground that the treatment is not reasonably necessary, the burden of proof shall be on the employer.  If the treatment is controverted on the grounds that the treatment is either not authorized or is unrelated to the compensable injury, the burden of proof shall be upon the employee.

(2)  In the event of a dispute as to the necessity and/or reasonableness of services already rendered, the procedure listed in Board Rule 203(c) shall be followed.

(d)  If an employer or insurer utilizes a Board certified WC/MCO pursuant to O.C.G.A. § 34-9-201(b)(3), and a dispute arises regarding the treatment/test prescribed by the authorized treating physician and the dispute is not resolved within 30 days as outlined in Rule 208(f), then the employer or insurer has 15 days from notification by the WC/MCO to authorize the treatment/test or controvert the treatment/test.  In no event will the employer or insurer utilizing a WC/MCO have more than 45 days from the receipt of the notice of a dispute as set forth in Rule 208(f) to comply with this provision.

(4)  Where the employer fails to comply with Rule 205(b)(3), the employer shall pay, in accordance with the Chapter, for the treatment/test requested.

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