Workers' Compensation Act.
(a) An insurer may require preauthorization for inpatient admission
to a hospital, inpatient admission to a treatment center, and
inpatient or outpatient surgery. The insurer's preauthorization
requirement must adhere to the following standards:
- The insurer may require no more than 10 days advance notice
of the inpatient admission or surgery.
- The insurer must respond to a request for preauthorization
within two business days of the request.
- The insurer shall review the need for the inpatient admission
or surgery and may require the employee to submit to an independent
medical examination as provided in
G.S. 97-27(a). This examination
must be completed and the insurer must make its determination
on the request for preauthorization within seven days of the date
of the request unless this time is extended by the Commission
for good cause.
- The insurer shall document its review findings and determination
in writing and shall provide a copy of the findings and determination
to the employee and the employee's attending physician, and, if
applicable, to the hospital or treatment center.
- The insurer shall authorize the inpatient admission or surgery
when it requires the employee to submit to a medical examination
as provided in G.S. 97-27(a)
and the examining physician concurs
with the original recommendation for the inpatient admission or
surgery. The insurer shall also authorize the inpatient admission
or surgery when the employee obtains a second opinion from a physician
approved by the insurer or the Commission, and the second physician
concurs with the original recommendation for the inpatient admission
or surgery. However, the insurer shall not be required by this
subdivision to authorize the inpatient admission or surgery if
it denies liability under this Article for the particular medical
condition for which the services are sought.
- Except as provided in subsection (c) of this section, the
insurer may reduce its reimbursement of the provider's eligible
charges under this Article by up to fifty percent (50%) if the
insurer has notified the provider in writing of its preauthorization
requirement and the provider failed to timely obtain preauthorization.
The employee shall not be liable for the balance of the charges
- The insurer shall adhere to all other procedures for preauthorization
prescribed by the Commission.
(b) An insurer may not impose a preauthorization requirement for
- Emergency services;
- Services rendered in the diagnosis or treatment of an injury
or illness for which the insurer has not admitted liability or
authorized payment for treatment pursuant to this Article; and
- Services rendered in the diagnosis and treatment of a specific
medical condition for which the insurer has not admitted liability
or authorized payment for treatment although the insurer admits
the employee has suffered a compensable injury or illness.
(c) The Commission may, upon reasonable grounds, upon the request
of the employee or provider, authorize treatment for which preauthorization
is otherwise required by this section but was not obtained if
the Commission determines that the treatment is or was reasonably
required to effect a cure or give relief.
(d) The Commission may adopt procedures governing the use of preauthorization
requirements and expeditious review of preauthorization denials.
(e) A managed care organization may impose preauthorization requirements
consistent with the provisions of Chapter 58 of the General Statutes.
(f) A provider that refuses to treat an employee for other than
an emergency medical condition because preauthorization has not
been obtained shall be immune from liability in any civil action
for the refusal to treat the employee because of lack of preauthorization.
(1993 (Reg. Sess., 1994), c. 679, s. 2.2.)
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of Contents page for Chapter 97. Workers' Compensation Act.
Text of Chapter 97. Workers' Compensation Act.
N.C. Industrial Commission ·
4340 Mail Service Center ·
Raleigh, NC 27699-4340
Main Telephone: (919) 807-2500 ·
Fax: (919) 715-0282
NCIC Home Page: http://www.ic.nc.gov/