Georgia > Workers Comp
Request For Authorization Of Treatment Or Testing By Authorized Medical Provider WC-205 - Georgia
| Request For Authorization Of Treatment Or Testing By Authorized Medical Provider Form. This is a Georgia form and can be used in Workers Comp . |
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WC-205 TREATMENT OR TESTING BY AUTHORIZED MEDICAL PROVIDER GEORGIA STATE BOARD OF WORKERS' COMPENSATION REQUEST FOR AUTHORIZATION OF TREATMENT OR TESTING BY AUTHORIZED MEDICAL PROVIDER Advance authorization for the medical treatment or testing of an injured employee is not required by the Georgia Workers' Compensation Act as a condition for payment of services rendered. However, an authorized medical provider may request advanced authorization for treatment or testing by completing Sections I and 2 of this form and faxing or e-mailing same to the insurer/self-insurer. The insurer/self-insurer shall respond to this request within 5 business days of receipt of this form by completing Section 3 below. If the insurer/self-insurer fails to respond to this request within the 5-day period, the treatment or testing stands pre-approved. See, Board Rule 205. NEITHER THE REQUEST NOR THE RESPONSE SHALL BE FILED WITH THE BOARD, UNLESS OTHERWISE REQUESTED. Honorable Richard S. Thompson, Chairman State Board of Workers' Compensation SECTION 1. IDENTIFYING INFORMATION Last Name First Name M.I. SSN or Board Tracking # Date of Accident PATIENT Employer Name Insurer / Self-Insurer Name Adjuster Insurer/Self-insurer phone number Insurer/Self-insurer E-mail Insurer/Self-insurer Fax number SECTION 2. REQUEST FOR TREATMENT OR TESTING AUTHORIZATION Diagnosis ICD-9 Code Requested Treatment or Testing CPT/DRG Code Who is to provide treatment or testing? Reason for treatment or testing Requesting authorized medical provider Address Phone Number Fax Number City E-mail Sate Zip Code Faxed I hereby certify that this completed form was Signature of Authorized Requesting Medical Provider Emailed to the Insurer / Self-Insurer on this the (day) day of (month) , (year) SECTION 3. RESPONSE OF INSURER TO REQUEST FOR TREATMENT OR TESTING AUTHORIZATION (Check appropriate item(s) and return to requesting Medical Provider by Fax or E-mail) The requested Treatment or Testing is authorized The requested Treatment or Testing is not authorized because it is: a. Not related to the on-the-job injury b. Not reasonably required to effect a cure, give relief or restore employee to suitable employment c. Not being provided by an authorized, panel or referral medical provider; d. Additional information needed (specify) e. Other (specify) Faxed I hereby certify that this Response was Signature of Insurer/Self-Insurer Representative Emailed to the requesting medical provider on this the (day) day of (month) , (year) -656-3818 OR 1-800-533-0682 OR VISIT http://www.sbwc.georgia.gov WILLFULLY MAKING A FALSE STATEMENT FOR THE PURPOSE OF OBTAINING OR DENYING BENEFITS IS A CRIME SUBJECT TO PENALTIES OF UP TO $10,000.00 PER VIOLATION (O.C.G.A. 34-9-18 AND 34-9-19). WC-205 REVISION . 07/2011 205 1 OF 2 TREATMENT OR TESTING BY AUTHORIZED MEDICAL PROVIDER American LegalNet, Inc. www.FormsWorkFlow.com WC-205 TREATMENT OR TESTING BY AUTHORIZED MEDICAL PROVIDER GEORGIA STATE BOARD OF WORKERS' COMPENSATION Advance authorization for the medical treatment or testing of an employee is not required by the Workers' Compensation Act. However, in the event an authorized provider requests pre authorization/pre-certification for treatment or tests of an employee and submits this form for such preauthorization/pre-certification to the insurer/self-insurer, the insurer/self-insurer shall respond, in writing, to this request within 5 business days from its receipt. A written request or response under this subsection shall be by facsimile transmission or e-mail. Any response to this request shall be sent directly to the requesting authorized medical provider. If the insurer/self-insurer fails to respond by completing Section 3 of this form within 5 business days, the treatment or testing stands pre-approved. Neither the request nor the response shall be filed with the Board, unless otherwise requested. In the event the insurer/self-insurer furnishes an initial written refusal to authorize the requested treatment or testing within the 5 business day period, then within 21 days of the initial receipt of the request for the requested treatment or testing, the insurer/self-insurer shall either: (a) Authorize the requested treatment or testing in writing; or (b) File with the Board a Form WC-3 controverting the treatment or testing and set forth the specific grounds for the controversion. Advance authorization procedures for medical providers participating in a Board approved WC/MCO may be governed by the applicable contract and may vary from the provisions above. Questions regarding the applicability of the provisions above should be addressed to the plan administrator or Managed Care Division of the State Board of Workers' Compensation (404) 656-3784. -656-3818 OR 1-800-533-0682 OR VISIT http://www.sbwc.georgia.gov WILLFULLY MAKING A FALSE STATEMENT FOR THE PURPOSE OF OBTAINING OR DENYING BENEFITS IS A CRIME SUBJECT TO PENALTIES OF UP TO $10,000.00 PER VIOLATION (O.C.G.A. 34-9-18 AND 34-9-19). WC-205 REVISION . 07/2011 205 2 OF 2 TREATMENT OR TESTING BY AUTHORIZED MEDICAL PROVIDER American LegalNet, Inc. www.FormsWorkFlow.com
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