Western Integrated Care uses a prior authorization process.
Effective 11/1/19 Western Integrated Care Prior Authorization Program provides its MPN physicians the authority to perform routine medical procedures without utilization review for claims wherein liability has been accepted, or liability is on delay but meets the requirement for provision of medical treatment of up to $10,000 per LC §5402(c). MPN physicians shall provide treatment consistent with MTUS.
This document serves as a guide to assist MPN Providers in determining which procedures are pre-authorized under this program and which ones require submission of DWC Form RFA to be processed for utilization review. The goal is to provide timely and quality medical care supported by evidence-based medicine guidelines and best practice.
All treatment must follow Title 8 CCR §9792.20 – 9792.24.3 MTUS criteria. Western Integrated Care MPN provider is Networks By Design and can be accessed at netbyd.com. This Prior Authorization Program pertains only to Providers in the Networks by Design MPN.
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General Instructions:
- No DWC RFA for the services or treatments provided to the injured worker under the Prior Authorization Program should be submitted.
- A PR-2 or 5021 must be submitted and indicate clearly that the services and procedures rendered supports the medical necessity of the treatment provided.
- All reports and documents are to be faxed to Benchmark Administrators within 8 hours to 909-843-9156.
- No certification letter will be sent by Western Integrated Care for the procedures and services that fall under this program.
- Please note: Initial diagnostic tests or procedures must be provided by Western Integrated Care Contracted Providers unless otherwise noted below.
- Per CA Department of Industrial Relations, Title 8, Section §5.5.1, Utilization Review Standards, Section §9792.7(a)(5). The following services and/or procedures shall be considered authorized. The provider shall not be required to submit requests through utilization review for these services. For all services and/or procedures not addressed on this list, please submit requests for authorization directly to the claim’s administrator.
Pre-Authorized services under Western Integrated Care Prior Authorization include the following services or ancillary services:
| Physical Medicine |
• Up to 12 physical therapy or occupational therapy visits per claim • Up to 12 chiropractic visits per claim • Up to 12 acupuncture visits per claim • All Physical Medicine must be provided by Orchid @ 866-888-6724 |
| Follow Up Visits/Specialty Referrals |
• Routine follow ups • Specialty Referral • When diagnosis of hernia is made on initial visit, referral to a General Surgeon is to be made immediately. |
| Medications |
• Over the counter medications • Up to 90 days of MTUS Formulary Generic Drugs • First Care may dispense 1st fill. • Up to one-month prescription of narcotic pain medication administered in first month of injury. Only Norco, Darvocet, Tramadol (Ultram) • Up to 90 days of generic muscle relaxants where the patient has acute muscle spasm • Continued prescription refills for patients when the claims administrator has given pre-approval for longer term medication use. For a duration of 6 months of refills. • All prescriptions beyond the initial 30 days must be dispensed through Definiti. Except Kaiser. |
| Diagnostic Testing |
• Initial x-ray • Initial MRI • Initial CT • Initial EMG/NCS • First Care may provide initial X-Ray • MRI, CT, EMG/NCS must be provided by Orchid Medical @ 866-888-6724. Except Kaiser. |
| Injections |
• Up to 3 Corticosteroid Injections. Improvement must be shown after initial injection. Other Services • Tetanus Shot if over 10 years from last injection • Pre-Op Medical Clearance if surgery authorized: CBC, EKG, UA, BMP |
| Durable Medical Equipment |
• Standard wheelchair • Crutches • Off the shelf braces • Tens Unit (2 or 4 leads) – 60 day rental • Splints • Walking Boots • Cold packs • Standard Prefabricated Orthotics • All DME items costing less than $200 may be supplied by initial treating physician. |
Per CA Department of Industrial Relations, Title 8, Section 5.5.1, Utilization Review Standards, Section 9792.7(a)(5). The following services and/or procedures shall be considered authorized. The provider shall not be required to submit requests through utilization review for these services. For all services and/or procedures not addressed on this list, please submit requests for authorization directly to the claim’s administrator.