Rule 16-Requests for Prior Authorization for Medical

Services

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If the request for prior authorization is properly made, the payer has how many days to respond:

c. 7 business days

b. 14 calendar days

a. 14 business days

Rule 16-Requests for Prior Authorization for Medical

Services

d. 7 calendar days

Which of the following is NOT a requirement for contesting a request for prior authorization for medical reasons:

d. A medical opinion

b. A certificate of mailing

a. A written response

Rule 16-Requests for Prior Authorization for Medical

Services

c. A copy of the response sent to the DOWC

According to the Rule, a proper request for prior authorization:

c. Must be made at least 7 business days before the service is to be

performed

b. Must be accompanied by supporting documentation

a. Can be verbal

Rule 16-Requests for Prior Authorization for Medical

Services

d. Must be accompanied by a certificate of mailing

Who is NOT permitted to transmit a provider’s written request for prior authorization to the payee:

c. The claimant’s sister

b. The claimant’s attorney

a. The claimant

Rule 16-Requests for Prior Authorization for Medical

Services

d. All of the above may transmit a provider’s written request for prior

authorization to the payee

If the payer is going to contest the request for non-medical reasons, they do NOT need to:

c. Include a certificate of mailing

b. Respond within the same required response period as a

denial for medical reasons

a. Attach a medical opinion to support their decision

Rule 16-Requests for Prior Authorization for Medical

Services

d. Be specific about the reason(s) for the denial

Pursuant to Rule 16-10, which of the following is NOT an acceptable reason for contesting a request for prior authorization based on non-medical reason(s):

d. The body part which the ATP says is related has not been

accepted as the responsibility of the carrier

c. The requestor is not an authorized provider

b. The claim has been denied due to statute of limitations defense

Rule 16-Requests for Prior Authorization for Medical

Services

a. The claim has been denied for lack of insurance coverage

Which statement below is true about the medical professional the payer selects to write an opinion regarding the request for prior authorization:

d. They must either be the same specialty as the requestor or have experience

managing that type of specialty

b. They must be the same expert the carrier uses at hearing

a. They do not have to be licensed in the State of Colorado

Rule 16-Requests for Prior Authorization for Medical

Services

c. Their report must comply with the same requirements for content as are required

of a DIME physician

If a payer misses a deadline for responding to a properly submitted request for prior authorization, which of the following will definitely NOT happen:

c. The payor may be subject to a penalty of up to $500 per day

b. The provider does not have to accept the Colorado Fee Schedule

a. The service will be automatically authorized

Rule 16-Requests for Prior Authorization for Medical

Services

d. The offending adjustor may be disciplined

One way to avoid automatic authorization when the payer does not strictly comply with requirements of the Rule within the compliance period is to:

c. File a motion with the DOWC which requests a reasonable period of time to

send a completed response

b. Wait until you have prepared a response which strictly complies with the Rule

a. Have your attorney file an application for hearing on the issue of medical

benefits within 7 business days of the request and advise the payee of the denial

Rule 16-Requests for Prior Authorization for Medical

Services

d. Within the response period, set a prehearing or settlement conference on

the issue even if does not occur until after the response deadline