Ala. Admin. Code r. 480-5-5-.08
Current through Register Vol. 43, No. 1, October 31, 2024
Section 480-5-5-.08 - Pre-Certification Required(1) Application for pre-certification shall be made as early as possible by the provider prior to rendering of the medical services for a compensable illness or injury. If medical services are for treatment of a medical emergency, notification shall be made by the provider to the employer/agent no later than the next working day.(2) The following medical services shall require authorization and pre-certification to be eligible for reimbursement: (a) Non-emergency admissions to inpatient facilities of any type including, but not limited to skilled nursing facilities;(b) Elective medical services performed in an ambulatory surgery center or the outpatient surgery department of a hospital or as part of an inpatient admission;(c) Outpatient physical therapy, occupational therapy and speech therapy services;(d) Chiropractic services;(e) Repeat baseline diagnostic studies where the clinical condition of the patient is unchanged since the initial study, and the initial study is available to the specialist in an appropriate time frame;(f) Cases selected by the employer/agent for focused medical management, which may include, but not be limited to, referrals to a specific specialist;(i) Pain management or outpatient pain clinics;(l) Durable medical equipment (other than braces, splints, etc., routinely provided in physician's office) including all items exceeding a reimbursement of $500.00, all Transcutaneous Electrical Nerve Stimulation (TENS) units, and all rental items; (n) Chemical dependency outpatient programs;(o) Weight loss programs or clinics;(p) Non-emergency dental services of all types;(q) Magnetic Resonance Imaging (MRI);(r) Computerized Axial Tomography (CAT) scans;(s) Myelograms, discograms, or surface electromyograms;(t) Psychiatric or psychological therapy or testing resulting from a compensable injury or trauma;(w) Stellate Ganglion Blocks; and(3) The review process may be used to identify and refer cases for discharge planning, generally, as related to post hospitalization services.(4) The RUE or employer/agent shall in the case of a denial of pre-certification or medical services, provide written (letter or facsimile) notification of the review decision to the requesting provider.(5) The employer/agent shall maintain appropriate internal documentation of each request for pre-certification to verify the process and the decision for claims processing, reporting, and audit purposes.(6) Physicians and other referring providers shall, except for an emergency, request pre-certification at least 48 hours or two working days prior to hospitalization or other medical services requiring pre-certification.(7) This Rule is not intended to and shall not be deemed to supersede any agreement or other arrangements between providers and payors regarding what procedures or sites shall be precertified. Author: Workers' Compensation Medical Services Board
Ala. Admin. Code r. 480-5-5-.08
New Rule: Filed August 9, 1996; effective September 13, 1996. Amended: Filed July 14, 1997; effective August 18, 1997.Statutory Authority:Code of Ala. 1975, § 25-5-293.