West Virginia Code of State Rules › Agency 85 - Workers' Compensation › Title 85 - PROCEDURAL RULE WORKERS' COMPENSATION RULES OF THE WEST VIRGINIA INSURANCE COMMISSIONER › Series 85-20 - Medical Management Of Claims, Guidelines For Impairment Evaluations, Evidence, And Ratings, And Ranges Of Permanent Partial Disability Awards › Section 85-20-22 - Consultations

Current through Register Vol. XLI, No. 28, July 12, 2024
22.1. The treating
				physician may refer an injured worker for a first-time consultation without
				prior authorizationwhen the need can be clearly documented and has been
				reported to the Commission, Insurance Commissioner, private carrier or
				self-insured employer, whichever is applicable. The first-time consultation to
				a specialist does not require prior authorization; however, should additional
				consultations in the same specialty field be performed, Commission, Insurance
				Commissioner, private carrier or self-insured employer, whichever is
				applicable, approval is required.
22.2. The consultant must submit a written
				report to the Commission, Insurance Commissioner, private carrier or
				self-insured employer, whichever is applicable, after the exam has been carried
				out. The report shall contain the information required in Rule 8.2 and 8.1
				above. Invoices from providers, other than the attending physician, should
				specify the name of the referring physician. In billing those services, the
				appropriate consultation procedure code from the Evaluation and Management
				section of the AMA CPT coding system shall be utilized.
22.3. If a specialist will be providing
				continuing care, the Commission, Insurance Commissioner, private carrier or
				self-insured employer, whichever is applicable, must be notified so that an
				approval for a transfer or concurrent care may be considered.
22.4. The Commission, Insurance Commissioner,
				private carrier or self-insured employer, whichever is applicable, reserves the
				right to arrange a consultation prior to authorizing any services, equipment,
				or supplies. Requests for treatment will be approved or denied upon review of
				the entire medical record.
22.5.
				Consultation Versus Referral. A consultation is considered to include those
				services rendered by a specialist whose review and opinion of the evaluation
				and/or treatment of an injured worker's condition is requested by another
				provider, or an official party in the claim, such as the injured worker's
				attorney, the employer, the Commission, Insurance Commissioner, private carrier
				or self-insured employer, whichever is applicable, etc. The consulting provider
				must submit a written report that becomes part of the Commission's, Insurance
				Commissioner's, private carrier's or self-insured employer's, whichever is
				applicable, claim record on the injured worker. When the consulting provider
				assumes the continuing care of the injured worker, any subsequent services
				rendered by this provider are no longer considered a consultation.
22.6. A referral is considered to be the
				transfer of the total or specific care of a patient from one provider to
				another. If this involves a change of treating physician, an authorization is
				required from the Commission, Insurance Commissioner, private carrier or
				self-insured employer, whichever is applicable. A referral for specialty
				services, such as surgery, requires approval by the Commission, Insurance
				Commissioner, private carrier or self-insured employer, whichever is
				applicable.