Workers’ compensation provides financial compensation for a variety of expenses you incur as a result of your work injury, including coverage for necessary surgical procedures. If your doctor determines that you need surgery to address a condition that develops as a result of a work injury, they will inform your employer’s insurance company of their determination. This is known as “prior notification,” and once the insurance company has been notified of this determination, they have seven business days to respond.
The insurance company typically responds in one of five different ways to this prior notification. In today’s blog, we take a closer look at the five ways insurance may respond to a request for workers’ compensation coverage for a surgical procedure related to a work injury.
How The Insurance Company Will Respond To Prior Notification Before Surgery
Emergency surgery will be covered without the need for prior authorization, but if the procedure is not emergent in nature, the insurance company has seven business days to take action on prior notification determination. Here are the five ways they are likely to respond to your request for coverage for surgical treatment related to your work injury.
1. Approval – This is the best case scenario. This means the insurance company has reviewed your doctor’s findings and agrees to provide coverage for surgery.
2. Denial– Conversely, the insurance company may also flat out reject the request for coverage. You can appeal this decision, and you can seek coverage through your individual healthcare provider while you appeal the initial ruling.
3. Request For More Information – The insurance company may also reply with a request for additional information about certain aspects of your condition or medical report. They will have seven business days to respond once this information has been provided to them.
4. Request For Second Opinion– Prior to greenlighting surgery, the insurance company may reply with a request that you seek out a second medical opinion. Once the second medical evaluation has taken place and that information has been provided to the insurance company, they will have seven business days to issue a determination.
5. Requesting A Specific Medical Evaluation– Finally, the insurance company may respond saying that you need to undergo an evaluation by a medical provider of their choosing before they make a determination. They will pay all costs associated with this exam, and this doctor will provide an opinion as to the reasonableness of surgery to the insurance company. If this is requested, the insurance company has 45 days from the date of the request to approve or deny surgery. If this request is made within seven business days of prior notification, the surgery needs to be put on hold until this examination takes place. However, if 45 days pass from the day that the insurance company made this request, and a decision about surgery approval still hasn’t taken place, your doctor can move forward with surgery and the worker will be covered. If the insurance company denies surgery based on this examination, the worker and their legal team can appeal this decision.
If you receive notification that your request for surgical insurance coverage has been denied, let us advocate on your behalf and ensure you get the financial protections you deserve. For more information, reach out to Dean and the team at Margolis Law Firm today at (952) 230-2700.
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