GQ Corner
Q: The claimant sent an email to the carrier and her employer in reference to her workers’ compensation claim, personnel issues, and an alleged new injury. She did not cc her attorney on the email. Is the carrier required to forward this correspondence to her attorney?
A: Yes, you should forward to the attorney. It is possible that the email had a blind cc on it to the claimant’s attorney, but to be sure, you should forward to the attorney and advise him that you have not responded to or communicated to the claimant without copying him. Furthermore, if there is any response you are obliged to make, send it only to the attorney.
Q: I have a network claim with an approved work hardening for a lumbar sprain/strain. However, a sprain/strain is not in the ODG for work hardening. Can I deny the bill when it is outside of ODG but the Utilization review approves it? Furthermore, additional treatment was also requested and approved as medically necessary, even though it exceeds the amount approved by the ODG. Would this have to be paid as well?
A: The network provider contract will control, but most likely does not allow the Carrier to dispute approved services based on medical necessity.
In a non-network context where preauthorization is covered by Rule 134.600, if the URA preapproves the service, the Carrier cannot dispute the bill based on medical necessity. The carrier can review the bill for extent of injury/relatedness issues, fee guideline adjustment, bill submission errors and documentation requirements.
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