4.5.26 Medical specialist consultations
Agents may receive requests from providers for prior approval of medical specialist consultations.
Prior approval is not required for medical specialist consultations.
Prior approval from the Agent is only required for elective surgical procedures including implantable pain therapy and prosthetic items.
WorkSafe note that Agents may receive requests or invoices for medical specialist consultations that may not clearly be related to the accepted work-related An injury/disease is work related if it arose out of or in the course of employment and the scope of employment. injury, or where there has been a gap in treatment. In such circumstances, Agents should:
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use their discretion to pay for these consultations as a once-off (unless existing information on file adequately supports an upfront denial of the request/invoice)
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request further information to support the relationship, if any, between the speciality and the workers' accepted work-related injury
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determine, upon receipt of the further information or in absence of further information following reasonable attempts to obtain it, if ongoing consultations for the speciality are reasonable
Agents must notify the injured worker and provider of any decision to cease funding of further medical specialist consultations for a particular speciality.
Agents should not be rejecting payment for medical specialist consultations where:
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there has been no procedure conducted alongside the medical specialist consultation item number, and/or
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where the Agent has not previously advised the injured worker and provider of any decision to cease funding of medical specialist consultations for a particular speciality