CompFox AI Summary
This case involves a dispute over whether a Medical Provider Network (MPN) physician's recommended treatment requires Utilization Review (UR) before authorization. The Appeals Board rescinded the prior award, holding that MPN second opinion physician recommendations are not exempt from UR. The Board clarified that while MPN dispute resolution exists, it does not preclude the insurer's right to UR. However, the matter was returned for further proceedings to determine if a proper Request for Authorization (RFA) was submitted, as an improperly submitted RFA would relieve the insurer of its UR obligation.
Full Decision Text1 Pages
This case involves a dispute over whether a Medical Provider Network (MPN) physician's recommended treatment requires Utilization Review (UR) before authorization. The Appeals Board rescinded the prior award, holding that MPN second opinion physician recommendations are not exempt from UR. The Board clarified that while MPN dispute resolution exists, it does not preclude the insurer's right to UR. However, the matter was returned for further proceedings to determine if a proper Request for Authorization (RFA) was submitted, as an improperly submitted RFA would relieve the insurer of its UR obligation.
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