§ 97-25.3. Preauthorization.
§97‑25.3. Preauthorization.
(a) An insurer mayrequire preauthorization for inpatient admission to a hospital, inpatientadmission to a treatment center, and inpatient or outpatient surgery. Theinsurer's preauthorization requirement must adhere to the following standards:
(1) The insurer mayrequire no more than 10 days advance notice of the inpatient admission orsurgery.
(2) The insurer mustrespond to a request for preauthorization within two business days of therequest.
(3) The insurer shallreview the need for the inpatient admission or surgery and may require theemployee 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 determinationon the request for preauthorization within seven days of the date of therequest unless this time is extended by the Commission for good cause.
(4) The insurer shalldocument its review findings and determination in writing and shall provide acopy of the findings and determination to the employee and the employee'sattending physician, and, if applicable, to the hospital or treatment center.
(5) The insurer shallauthorize the inpatient admission or surgery when it requires the employee tosubmit to a medical examination as provided in G.S. 97‑27(a) and theexamining physician concurs with the original recommendation for the inpatientadmission or surgery. The insurer shall also authorize the inpatient admissionor surgery when the employee obtains a second opinion from a physician approvedby the insurer or the Commission, and the second physician concurs with theoriginal recommendation for the inpatient admission or surgery. However, theinsurer shall not be required by this subdivision to authorize the inpatientadmission or surgery if it denies liability under this Article for theparticular medical condition for which the services are sought.
(6) Except as providedin subsection (c) of this section, the insurer may reduce its reimbursement ofthe provider's eligible charges under this Article by up to fifty percent (50%)if the insurer has notified the provider in writing of its preauthorizationrequirement and the provider failed to timely obtain preauthorization. Theemployee shall not be liable for the balance of the charges.
(7) The insurer shalladhere to all other procedures for preauthorization prescribed by theCommission.
(b) An insurer may notimpose a preauthorization requirement for the following:
(1) Emergency services;
(2) Services rendered inthe diagnosis or treatment of an injury or illness for which the insurer hasnot admitted liability or authorized payment for treatment pursuant to thisArticle; and
(3) Services rendered inthe diagnosis and treatment of a specific medical condition for which theinsurer has not admitted liability or authorized payment for treatment althoughthe 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 thissection but was not obtained if the Commission determines that the treatment isor was reasonably required to effect a cure or give relief.
(d) The Commission mayadopt procedures governing the use of preauthorization requirements andexpeditious review of preauthorization denials.
(e) A managed careorganization may impose preauthorization requirements consistent with theprovisions of Chapter 58 of the General Statutes.
(f) A provider that refusesto treat an employee for other than an emergency medical condition becausepreauthorization has not been obtained shall be immune from liability in anycivil action for the refusal to treat the employee because of lack ofpreauthorization. (1993 (Reg. Sess., 1994), c. 679, s. 2.2.)