Situations arise where the provider is unable to obtain a pre-authorization before services are delivered or to notify L&I within the specified time period of admission, e.g. 24 hours. In these situations, providers can request that L&I evaluate the claim as if those requirements had been met by following the process below.
Process:
- L&I will pay the for services related to state fund workplace injuries provided it was proper and necessary medical care, and was billed within one year of the date of service.
- If a provider failed to notify L&I about an admission or receive prior authorization they should contact L&I about retrospective authorization.
- In order for the provider to know who to contact at L&I for authorization they can use the fee lookup to find any prior authorization requirements for specific billing codes.
- For example, if the service required utilization review through Comagine Health, the provider should contact Comagine.
- If you are calling for authorization or a retro-authorization please be ready with your provider number, the INSURED’S I.D. NUMBER, procedure codes, dates of service, referring physician and basis for the request.
Tips
- If a bill denies, the estimate of benefit (EOB) will explain to the provider how to seek authorization.
- See “Getting a Payment Adjusted”
- Need further assistance? Call the Provider Hotline: 1-800-848-0811