Fill and Sign the Form 223 Rev3 17docx

          NOTICE TO INJURED WORKER: If you disagree with the carrier and cannot resolve your differences by talking with the carrier and/or your treating physician, you should then call the Labor Commission, Division of Industrial Accidents, for further instructions.     Official Form 223 Revised 03/17 State of Utah - Labor Commission – Division of Industrial Accidents 160 East 300 South * P O Box 146610 Salt Lake City, UT 84114-6610 Telephone: 801-530-6800 * Toll Free: (800) 530-5090 * Fax: 801-530-6804 Email: IACCD@utah.gov * Website: www.laborcommission.utah.gov Form 223 Last Name First Middle Street Address, City, State, Zip Social Security Number Date of Birth Phone Number Date of Injury Employer's Name Street Address, City, State, Zip Phone Number Nam e Str e e t Ad d r e ss, Ci ty , State , Zi p Adjuster Phone Number Fax Number Provider's Name Street Address, City, State, Zip Degree and Specialty Phone Number Fax Number Diagnosis Best Time to Contact Provider (Business Days) Date of Verified Transmission Requested Procedure(s) - Attach Supporting Documentation, If Needed Date of Verified Transmission Responsible Person Acceptance Signature Denial Signature (Attached Criteria Utilized) Date of Verified Transmission OPTIONAL - Explanation and/or Additional Information Date of Verified Transmission Responsible Person Acceptance Signature Denial Signature (Attached Criteria Utilized) Date Pati e n t's Si gn atu r e PATIENT'S ACKNOWLEDGEMENT OF RESPONSIBILITY IF PROCEDURE IS DENIED BY CARRIER I agree that I m ay becom e liable for the cost of the m edical procedure if it is ultim ately determ ined to not be com pensable. P A T I E N T PLEASE PRINT OR TYPE Authorization Request for Medical Treatment / Carrier Response CARRIER'S RESPONSE (Level One) C A R R I E R PROVIDER'S REQUEST FOR CARRIER'S PHYSICIAN REVIEW (Level Two) P R O V I D E R C A R R I E R CARRIER'S PHYSICIAN'S RESPONSE (Level Two) P A T I E N T C A R R I E R PRO V IDE R'S INIT IAL RE QUE S T ( Le v e l O ne ) P R O V I D E R Form 223 – Instructions The use of Form 223 is governed by the Division of Industrial Accident’s Rule R612-300-11 “Utilization Review Standards.” A treating physician may use Form 223 to request authorization for payment for a course of proposed treatment, including surgery, hospitalization or any diagnostic study beyond plain X-rays. Levels of Review Level I: The treating physician sends this form with the Provider’s Initial Request (Level One) portion completed, along with documentation for the requested treatment, to the payer of the claim. The payer is to notify the treating physician within five (5) business days with approval or denial of the request. The payer may use medical or non-medical personnel at this level to make the decision to approve or deny the request. If the request is denied, the payer must send the criteria used in making the decision to deny payment for the procedure requested. Level II: A physician who has been denied authorization for payment for treatment, or has received no response to the request within the five (5) days, may request physician’s review of the request by sending the completed Provider’s Request for Carrier’s Physician Review (Level Two) portion of the request for physician review. The requesting physician is to include the days and times that he/she is available to discuss the case with a reviewing physician. The payer’s physician reviewer must make a reasonable attempt to contact the treating physician regarding the payer’s denial and must complete the review within five (5) business days of the treating physician’s request for review. If the authorization for payment for the treatment is denied, the carrier’s reviewing physician must send the criteria used to make the decision along with the name and specialty of the reviewing physician to the treating physician. If the treating physician proceeds with the treatment without the approval of the payer and the treatment is a non-emergency, the payer is liable for only 75% of the amount otherwise payable if the Labor Commission deems the treatment reasonable to treat the industrial injury. The 25% reduction does not apply if the treating physician receives authorization from the injured worker’s health insurance plan. For a complete text of the rule you may access the rule (R612-300-11) through the Labor Commission’s website at www.laborcommission.utah.gov.