Reminder: Denials of PARs without a Carrier’s Physician Review and Signature are Invalid and Subject to Penalty

As has been mentioned previously, please note that a prior authorization request (PAR) that has advanced to Level 2 review may only be denied by the carrier’s physician.

When a payer denies or partially approves a PAR (MTG Variance, MTG Special Services, MTG Confirmation, Medication, Durable Medical Equipment), the payer must also declare any other basis for denial or such basis for denial will be deemed waived. 

All Level 2 denials or partial approvals must be made by the carrier’s physician. A partial approval limits the length of time or frequency of the treatment, or authorizes a related but different treatment than the one requested in the PAR.

NOTE: If the PAR was submitted after the medical care was rendered, a medical opinion by the carrier’s physician, a review of records, or independent medical examination is not required, and the payer may deny the PAR on the basis that it was not requested before the medical care was provided.

More information

For full details and training materials, please see OnBoard for Payers.

Visit OnBoard Support and System Requirements for assistance with PARs, Request for Decision on Unpaid Medical Bills (Form HP-1.0) submissions, technical issues, and more.

The Board has also created a special webpage dedicated to sharing timely updates on various Board initiatives with a payer focus. Visit What Payers Need to Know to view the latest.