4.3.1 Seek prior approval of services | 4.3.2 Receive account or receipt | 4.3.3 Determine what is reasonable & necessary | 4.3.4 Progress reports to decide reasonableness| 4.3.5 Review ongoing entitlement
Some services require prior approval before the services are provided. This applies both to an accepted claim, and where the worker is entitled to provisional payments for a claimed mental injury.
For example, prior approval may be required for specialist services such as surgery or inpatient hospital treatment.
The Agent will either:
- accept liability or
- deny liability
for the service.
To obtain prior approval, the worker’s treating practitioner submits a written request with supporting medical evidence, that outlines the:
- details of the specific procedure/treatment
- need for the specific procedure/treatment
- relationship to the work-related injury/illness or to the claimed mental injury, in the case of treatment provided under provisional payments
- proposed date when the procedure/treatment will be provided
- where appropriate the item codes or cost of treatment or service.
Workers may be asked to provide further information or assist the Agent to obtain further information from their service provider.