Authorization Overview
The Authorization subsystem supports timely and accurate processing and review of authorization requests by adhering to the guidelines defined by the Department of Labor (DOL) staff. It expedites the payment for the Provider and reduces the potential for fraud and abuse.
Authorization requests are received in one of the following ways:
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Submitted via paper templates received in the Central Mailroom via fax or mail.
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Submitted by the provider via Direct Data Entry (DDE) from Provider Portal.
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Submitted by WCMBP or DOL staff via DDE within WCMBP System.
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Received via interface for DEEOIC Home Health Authorization and DCMWC Diary Action Code (DAC) Authorization.
In addition, the WCMBP System also supports processing of urgent and emergency authorization requests via call center. Emergency and urgent requests are transferred to a Triage Nurse who creates the authorization, communicates to the respective District Office (DO), and requests immediate authorization.
The WCMBP System verifies all authorization requests to ensure they contain valid information (for example, claimant’s case ID, claimant name, provider ID, diagnosis code, procedure code, and so on). All authorizations are assigned unique identification numbers and are associated with the specific program of the claimant.
The WCMBP System is integrated with the Treatment Suite (TS) to derive the authorization level for all requests.
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Level 1 requests do not require authorization and are automatically approved.
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Level 2 requests are reviewed and approved by WCMBP staff.
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In case of missing or invalid data, WCMBP Staff return the authorization to the Provider via Return to Provider (RTP) letter requesting resubmission with with corrected details.
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In case a request should be denied or if WCMBP Staff cannot reach a decision point, Level 2 requests are escalated to Level 3 requests.
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Level 3 requests are resolved by DOL staff within the WCMBP System.
When authorization is Approved, the WCMBP System generates an approval letter to be delivered to the provider.
For Level 3 requests where DOL Staff determines that further development is required, authorization status is updated to “Pended Further Development” and the WCMBP System triggers a letter to the provider stating that the request is under review by DOL.
DOL Staff is also responsible for communicating authorization denials to the Provider.
During the bill adjudication process, the bill is validated against the authorization results. For paid bills, the utilized unit or amount is deducted from the authorized unit or amount and real-time authorization status is made available to the requesting provider, claimant, and staff.