PROCEDURE TO DEAL WITH WORKERS’ COMPENSATION MEDICAL NECESSITY DENIALS

 

Here is the proper procedure for handling claims denials involving workers’ compensation patients in Arizona for care rendered that was in your judgment medically necessary.

 

First, continue to treat the patient until you have reached maximum medical improvement (MMI) for the work-related injuries. Then, if medically necessary care is denied based on the judgment of either a claims adjuster or an IME, do the following:

 

Fill out the “Request for a Hearing” form found on the Industrial Commission of Arizona website at http://www.ica.state.az.us/Claims/Claims_Request_for_Hearing.aspx. State clearly the reasons for the request for the hearing. The reasons can range from non-payment of a claim to the patient is still injured and needs additional care. Be sure to fill out the form as if the patient is writing it or have the patient write the form. The patient must sign the form.

 

Fax the form to the Industrial Commission at 602-542-3373. Fax it several times to make sure that they get it and it gets in the queue. It will take about 4-6 weeks to get the patient scheduled for a hearing with the Administrative Law Judge (ALJ). The patient will be notified, not you. You can, however, call and find out when the hearing. Call the Industrial Commission. Phone numbers are (602) 542-4661 and (520) 628-5181. Email: Claims@azica.gov.

 

Our members have had great luck with the ALJs. Proving your case is a lot easier with the judges than with the insurance company adjustors. Doctors usually get everything paid at least through the date of any IME. After that time, it is your word against the IME doctor so your reasoning and medical records need to be very strong but this can be done and you can win.

Usually, the ALJ’s secretary will call you for a deposition over the phone so all of this is very easy to do. You just have to know how the system works and now you do.

602-932-8113.