Providers treating a North Carolina workers' compensation patient send Form 25PR when they want the insurer to preauthorize a surgery or an inpatient admission. Page 1 carries the request with diagnosis, codes, setting and dates of service, and the insurer marks it authorized or denied on initial review. If it is denied, the provider completes page 2 to appeal, and the insurer's review professional records findings under G.S. 97-25.3.
The requesting provider's office completes the employee, provider, facility and request items on page 1, and the provider portion of page 2 when appealing. The insurer completes item 4 on page 1, and its review professional completes the qualifications, findings and determination on page 2.
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Request for Preauthorization of Medical Treatment
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Requests to preauthorize surgery or an inpatient admission on a North Carolina workers' compensation claim. The provider certifies that all pertinent clinical documentation is attached and describes the requested service, including body parts, diagnosis and CPT codes, setting, facility, and the dates or length of service.
Complete page 2 of the same form, which is for the provider to appeal the initial denial, and send it to the insurer's designated preauthorization contact. The insurer's review professional lists qualifications, specialty and licensure, records review findings and a determination under G.S. 97-25.3(a)(4), and notes whether a peer-to-peer was conducted.
To the insurer, not the Industrial Commission. The form says the health care provider transmits it to the insurer at the email address or fax number designated in the insurer's preauthorization review policy. Each page has space for the contact details of the claims adjuster or designated preauthorization agent.