W. Va. Code R. § 85-20-22

Current through Register Vol. XLI, No. 41, October 11, 2024

Section 85-20-22 - Consultations

22.1. The treating physician may refer an injured worker for a first-time consultation without prior authorizationwhen the need can be clearly documented and has been reported to the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable. The first-time consultation to a specialist does not require prior authorization; however, should additional consultations in the same specialty field be performed, Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, approval is required.

22.2. The consultant must submit a written report to the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, after the exam has been carried out. The report shall contain the information required in Rule 8.2 and 8.1 above. Invoices from providers, other than the attending physician, should specify the name of the referring physician. In billing those services, the appropriate consultation procedure code from the Evaluation and Management section of the AMA CPT coding system shall be utilized.

22.3. If a specialist will be providing continuing care, the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, must be notified so that an approval for a transfer or concurrent care may be considered.

22.4. The Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, reserves the right to arrange a consultation prior to authorizing any services, equipment, or supplies. Requests for treatment will be approved or denied upon review of the entire medical record.

22.5. Consultation Versus Referral. A consultation is considered to include those services rendered by a specialist whose review and opinion of the evaluation and/or treatment of an injured worker's condition is requested by another provider, or an official party in the claim, such as the injured worker's attorney, the employer, the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, etc. The consulting provider must submit a written report that becomes part of the Commission's, Insurance Commissioner's, private carrier's or self-insured employer's, whichever is applicable, claim record on the injured worker. When the consulting provider assumes the continuing care of the injured worker, any subsequent services rendered by this provider are no longer considered a consultation.

22.6. A referral is considered to be the transfer of the total or specific care of a patient from one provider to another. If this involves a change of treating physician, an authorization is required from the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable. A referral for specialty services, such as surgery, requires approval by the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable.

W. Va. Code R. § 85-20-22