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:

  1. 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.
  2. If a provider failed to notify L&I about an admission or receive prior authorization they should contact L&I about retrospective authorization.
  3. In order for the provider to know who to contact at L&I for authorization they can use the fee look-up utility to look-up 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