The State of Georgia has two medical provider systems by which an injured worker may seek treatment for a work-injury: Managed Care Organizations (MCOs) or a Traditional Panel. The majority of workers in this State will be treating under a Traditional Panel. If your patient is treating under an MCO, WC-205 may not be the most appropriate process for obtaining Advance Authorization for treatment.
If your patient is treating with you based on a Traditional Panel, and you are an Authorized Treating Provider, please be aware that the State of Georgia does not require pre-authorization for treatment. See, State Board of Workers’ Compensation Rule 205(b)(2) (“Advance authorization for the medical treatment or testing of an injured employee is not required…as a condition for payment of services rendered.”)
However, the State Board of Workers’ Compensation recognizes that doctors and other medical providers may be hesitant to provide treatment without authorization from the Insurance carrier. To help expedite authorization, the State Board created Form WC-205. This form can be used to request diagnostic studies, such as an MRI, to request treatment, such as epidural injections, or for referrals to other doctors. This form can also be used for studies or treatment which can rule in or rule out a diagnosis as provided in the Board Rule 205 (b)(1).
You may obtain a copy of the most recent Form WC-205, and other forms, at the State Board’s web site here.
Board Rule 205(b)(1):
“Medical treatment/tests prescribed by an authorized treating physician shall be paid, in accordance with the Act, where the treatment/tests are:
(a) Related to the on the job injury;
(b) Reasonably required and appear likely to accomplish any of the following:
- Effect a cure;
- Give relief;
- Restore the employee to suitable employment;
- Establish whether or not the medical condition of the employee is causally related to the compensable accident.”
Practical Limitations of Form WC-205
This request process is for claims in which the insurance company has deemed the injury compensable and you are an Authorized Treating Provider. For instance, if you are treating a patient for a work-related shoulder injury, you are the authorized doctor for that injury and need to request an MRI of the shoulder, Form WC-205 would be an appropriate method to obtain advance authorization. Similarly, if there is a question as to whether there is neck involvement, Form WC-205 could be used to request an MRI of the cervical spine to rule in or rule out the neck.
- Fill out the WC-205 Form. Be sure to fill out sections 1 and 2 as completely as possible. At the bottom of Section 2, be sure to indicate whether the form is being faxed or emailed and on what date. Be sure to have the requesting medical provider sign. If a member of the office staff is emailing or faxing the form, it would be helpful to indicate on the form who sent it.
- Add supporting documentation. Board Rule 205(b)(3)(a) reads in part, “An authorized medical provider may request advance authorization for treatment or testing by completing Sections 1 and 2 of Board Form WC-205 and faxing or emailing same to the insurer/self-insurer, along with supporting medical documentation.” Supporting medical documentation could include office notes from the requesting doctor and/or supporting treatment notes from another doctor and/or diagnostic testing.
- Retain Confirmation. If the form is faxed, retain the fax confirmation receipt. If the form is emailed, retain the email confirmation. If you can email with a read receipt, that is also helpful. This way your office has confirmation that the form was sent with receipt on the other end.
- The insurance company has 5 business days to respond to your request by facsimile or email.
- The insurance company may approve the request or they may deny it. If the insurance company denies the request, they must provide a reason for doing so by selecting boxes “a” through “e.” Please note that for “additional information needed” and “other,” the insurance company is required to specify what is missing or what other reason the request is being denied.
- If the request is denied, then, within 21 days of receipt of the WC-205, the insurance company may reconsider its denial of the request, may obtain additional information, or perform other due diligence. At the end of the 21 days, the insurance company must either approve the request, or formally deny the request by filing a Form WC-3 Notice to Controvert with the State Board and serve that Notice to Controvert upon the injured worker, his/her attorney, and the doctor who submitted the WC-205.
- The insurance company may also fail to respond. If, at the end of 5 business days, the insurer has not responded to the request at all, the treatment stands pre-approved. In other words, the State Board is approving the treatment. Please keep in mind that the approval is always subject to whether the injury is compensable. If it is clear that the injury is a work injury and treatment for that injury has been furnished in the past, then the treatment should be pre-approved. Please review Practical Limitations below.