North Carolina Utilization Review Process Policy and Procedure

This outlines the policies and procedures of the Walmart North Carolina Preauthorization Program (hereafter referred to as "the Program") which utilizes GENEX Services, LLC as the Utilization Review Agent.

In accordance with 04 NCAC 10A.1001, all surgeries and all inpatient treatments are subject to the preauthorization process. A request for authorization of any surgery or any inpatient treatments is classified as a "mandatory request" under the Program.

Although North Carolina does not require preauthorization for outpatient services, the Program may perform preauthorization and retrospective reviews at the direction of Walmart Claims Services, Inc., the third party administrator of Walmart's workers' compensation claims in North Carolina. This type of request is classified as a "voluntary request" under the Program.

A. Initiation of Initial Preauthorization Request

1. Requests for preauthorization can be made by workers' compensation health care providers, claimant's attorneys, unrepresented claimants, employers, insurers or third party claims administrators. The preauthorization requests shall be submitted on the Industrial Commission Form 25PR. The form can be obtained on the North Carolina web site at http://www.ic.nc.gov/forms/form25pr.pdf 04 NCAC 10A.1001(k).

2. The Form 25PR shall be transmitted to GENEX either by email at [email protected] or fax to 877-835-2684.

3. GENEX will send acknowledgement of the request to the requesting entity and insurer/claims administrator within 2 business days of receipt of the Form 25PR. 04 NCAC 10A.1001(k).

4. GENEX is available for communication via telephone, fax and/or email on a pending request for preauthorization (including Peer Review Physicians) on a continuous basis on every business day (which excludes weekends and holidays) between the hours of 8:00 AM and 8:00 PM Eastern Standard Time. 04 NCAC 10A.1001(e)(2)

5. After hours communication is accessible via phone mail between the hours of 8:00 PM and 8:00 AM Eastern Standard Time Monday through Friday and weekends & holidays. All calls received after hours will be responded to on the next business day.

6. All requests for service are registered into the GENEX computer system (CMS) by the GENEX Support Staff who verifies appropriate carrier, claim, and Injured Worker information and forwards the case to the GENEX Non-Physician Reviewer for review. These Reviewers are restricted from reviewing clinical information or making clinical decisions.

B. Initial Review Process by Non-Physician Reviewer (Nurse)

1. A GENEX Non-Physician Reviewer is a Registered Nurse (RN), Licensed Vocational Nurse (LVN) and/or Licensed Professional Nurse (LPN) who holds a current, unrestricted license in their state of residence.

2. Upon receipt of the clinical information, the Nurse evaluates the requested services for medical necessity of procedure/treatment and inpatient admissions, duration of care, and appropriateness of services and makes authorization decisions using specified criteria as previously stated. The Nurse has electronic and phone access to consult with an MD/DO or licensed health professional in the same licensure category as the requesting provider.

3. If the Nurse can authorize the request, she/he will notify the appropriate entities as outlined in section D "Time Frame Requirements."

4. If the Nurse is unable to authorize the request in its entirety, the request will be forwarded to a Peer Review Physician. Only physicians may modify or deny treatment requests.

5. No denial is based on a Nurse Review.

C. Review Process by Peer Review Physician

1. Clinical reviews are conducted by a GENEX Peer Review Physician on all cases where an authorization is not issued through the initial review.

2. The GENEX Peer Review Physician is a medical doctor, doctor of osteopathy, psychiatry, psychologist, acupuncturist, optometrist, dentist, podiatrist, or chiropractic practitioner currently licensed by North Carolina, South Carolina, Georgia, Virginia or Tennessee and shall hold professional qualifications, certifications, and fellowship training in a like specialty that is at least equal to that of the treating provider who is requesting preauthorization of surgery or inpatient treatment. 04 NCAC 10A.1001(i)

3. An opportunity for a Peer to Peer discussion is offered to the requesting provider prior to the determination being made. The Peer Review Physician is available to discuss the determination with the requesting provider at 800-382-9163 on any business day between 8:00 AM and 8:00 PM Eastern Standard Time. 04 NCAC 10A.1001(h) In the event the reviewer is unavailable, the requesting physician may discuss the request with another Peer Review Physician who is competent to evaluate the specific clinical issues involved in the medical treatment services. In the event no peer to peer discussion occurred, the Peer Review Physician makes the determination based on the information submitted.

4. Requests are not denied on the basis of lack of information unless a request to obtain the necessary information from the requesting physician occurs and the requested information is not provided in the appropriate timeframe (outlined in D below) and documentation of the attempt is retained by Genex.

5. Treatment is not denied on the sole basis that the treatment is not addressed by a guideline.

D. Time Frame Requirements

1. The first day in counting the timeframe requirement is the day after the receipt of the request.

2. The request determination shall be communicated to the requesting physician initially by telephone or fax within 7 business days of receipt of the request. 04 NCAC 10A.1001(l)

3. The communication by telephone/fax shall be followed by written notice and sent to the injured worker and/or the injured worker's representative, the insurer/claims administrator, the requesting physician and facility if known.

E. If a Peer to Peer discussion did not take place, GENEX will accept a phone call from the requesting provider within 24 hours of an adverse determination.

F. Appeal

1. The requesting provider, claimant's attorney, or unrepresented claimants have the right to submit a request for an appeal no later than the 30th calendar days after the date of the verbal or faxed notification of the modified or adverse determination. This is done by completing the 2nd page of Form 25PR and emailing or faxing along with any additional medical information to [email protected] or fax to 877-835-2684.

2. Appeals will follow the initial workflow as outlined above for initial review.

3. The appealing party has the right to seek authorization for any denied treatment from the Commission. 04 NCAC 10A.1001(e)(6)

G. Approvals Made by Claims Adjuster

The workers' compensation claims administrator may give approval for any Voluntary pre-authorization requests without formally referring the request to GENEX. The supervisor for Walmart's North Carolina claims administrator is Heather Pannell ([email protected]). Mailing address is Walmart Claims Services, Inc., PO Box 14731 Lexington, KY 40512. Telephone number is 800-527-0566 ext. 58127. Fax number is 877-219-0832. Normal business hours are 7:00 a.m. to 5:00 p.m. CST.

H. UR Credentialed Peer Review Physician Profiles