What to do if you receive an RFA (or anything that can be construed as an RFA) from a provider where liability is disputed

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What to do if you receive an RFA (or anything that can be construed as an RFA) from a provider where liability is disputed:

  1. Remember, you can issue a UR deferral within 5 days of receipt of an RFA where we dispute (1) liability for the injury itself or (2) liability for the recommended treatment for reasons other than medical necessity (non-industrial body part, non-MPN provider, more than 24 chiro visits, etc.)
  2. Timely issue the UR deferral! Many lien claimants hang their hat on examiners either not issuing a UR deferral where liability is disputed or issuing a late UR deferral.  Make sure that the date you receive the RFA is well documented in your claims file and that UR deferrals are issued.
  3. If liability for the injury itself or for the treatment is later established (e.g., industrial causation is established), make sure all RFAs previously deferred go through retro-UR within 30 days after liability is established. Example: Claim denied based on no medical evidence.  RFA received for chiro treatment.  Objection and UR deferrals are issued due to denial of claim.  Parties proceed to AME, who finds industrial causation exists.  Immediately send all previously deferred RFAs to UR ASAP!