A Vermont health care provider can use this optional form to ask the workers' compensation insurer to approve proposed treatment in advance, under 21 V.S.A. §640b and Rule 7.0000. The provider describes the treatment, billing code and extent, and attaches supporting records with a letter on medical necessity and work-relatedness. The insurer must approve, deny or order an IME or records review within 14 days.
The requesting physician or health care provider completes the injured worker, request and provider sections, certifies that the documentation and letter are attached, and signs. The adjuster completes the insurer action block and signs it.
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Request to Insurance Company for Preauthorization of Medical Treatment
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No. Form P1 itself notes that preauthorization is not required, but if a provider requests it, this form may be used. Requesting it produces a documented insurer decision within 14 days, or within 45 days when the insurer orders an independent medical exam or a records review.
The supporting medical documentation and the provider's letter explaining the reason for the treatment, its medical necessity and why it is related to the work injury. The provider also attaches verification showing when and how the form was sent to the insurer, by mail, fax or email.
The adjuster checks Denied and must attach a Form 2, Denial of Workers' Compensation Benefits, with supporting evidence. The adjuster also records the date the request was received, the date the adjuster signed and the date the response was sent.