1. First, know how long the adjuster has to approve or deny your doctor’s request.
- Your adjuster has 30 days to accept or deny your Nevada work comp claim. Expect only emergency care and clinic visits in the interim.
- If your doctor doesn’t think that diagnostic tests or treatment are necessary now, your only option is to ask for a provider list of alternate doctors. If you ask in writing within the first 90 days of your claim, the adjuster must approve it. The next doctor may agree that diagnostic tests
- Prior authorization is required for MRI’s, more than 6 physical therapy visits, surgery, neurological testing, or specialty consults.
- Nevada law gives the adjuster 5 working days from receipt of the doctor’s request form to approve or deny it. NRS 616C.157.
- Adjusters routinely ignore the 5-day rule by scheduling a second opinion consultation. Or, the adjuster may ask for a review by an outside doctor hired to control claims costs, particularly if a low back surgery is requested.
2. Find out why there is a delay.
- Don’t assume it’s the adjuster’s fault. Ask your doctor’s staff when they faxed the authorization form. It may not have been faxed for several days after you saw your doctor. Make sure they faxed an authorization form.
- The adjuster will also need the doctor’s dictated report if an expensive medical procedure is requested. The adjuster may also ask the doctor answer questions about preexisting conditions or what injuries were caused by this accident.
- Politely ask the adjuster whether she received the authorization form. If she didn’t get it, confirm her fax number, and ask your doctor to re-fax it to the correct number. If the adjuster claims she already returned the form, ask her to please re-fax it. Many delays are due to wrong fax numbers, misplaced faxes, or the doctor’s failure to send the necessary authorization form.
- Don’t resist any second surgical consultation the adjuster schedules. It will just delay things further and could result in a suspension of your benefits. However, if the adjuster wants multiple consults, she is probably going to deny your doctor’s treatment request. Get legal help soon.
- Using abusive language or calling the adjuster daily will only result in purposeful delayed action by the adjuster.
3. For denied or indefinite delays, you must write (or get help).
- If authorization is denied, don’t waste time arguing with the adjuster. Quickly file a request for hearing, and get your doctor’s reports to present your position to the hearing officer.
- For an indefinite delay send a fax to the adjuster, stating that NRS 616C.157 allows your doctor to proceed as if the request was approved when there is no response within 5 working days. When your doctor won’t proceed without a signed authorization, file a request for hearing with the Hearings Division. Attach a copy of your fax to the adjuster and a copy of the request form your doctor sent.
- Secondly, send DIR a complaint letter about the delay. Copy the adjuster. Attach your supporting documents. DIR may not be helpful, but the adjuster won’t want to take the risk of getting fined for a violation of the law. The adjuster will now quickly authorize the request or deny it, giving you the right to file an appeal. Promptly file any appeals within the 70-day time limit.
Virginia Hunt, Hunt