GQ Corner

Q. I understand that we have 15 days to pay or dispute a claim. However, if the 15th day falls on a weekend, does our deadline fall on the preceding business day or the next business day?

A. Rule 102.3(3) provides that “unless otherwise specified, if the last day of any period is not a working day, the period is extended to include the next day that is a working day” so it would be the next business day. However, as with all deadlines, the best practice is generally to file as far ahead of the deadline as possible to avoid allegations of waivers, untimely initiation of benefits, and so on.

Q. I have a claimant who is being prescribed an N-status drug but our utilization review agent (URA) will not pre-authorize it. Can I approve it anyway?

A. No. If your URA will not pre-authorize the medication, you may be found in violation if you paid for it. The Division, as a regulatory agency, continually emphasizes that adjusters are not to be directly involved in medical necessity determinations (which are the exclusive province of the URA) or to direct a claimant’s medical treatment generally.