Form WC188 "Authorized Treating Provider's Request for Prior Authorization" - Colorado

What Is Form WC188?

This is a legal form that was released by the Colorado Department of Labor and Employment - a government authority operating within Colorado. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2018;
  • The latest edition provided by the Colorado Department of Labor and Employment;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form WC188 by clicking the link below or browse more documents and templates provided by the Colorado Department of Labor and Employment.

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Download Form WC188 "Authorized Treating Provider's Request for Prior Authorization" - Colorado

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Instructions for Form WC 188
Authorized Treating Provider’s Request for Prior Authorization
Prior authorization for payment shall be requested by the authorized treating provider (ATP)
when:
(1)
A prescribed service exceeds the recommended limitations set forth in the
Medical Treatment Guidelines;
(2)
The Medical Treatment Guidelines otherwise require prior authorization for that
specific service;
(3)
A prescribed service is identified within the Medical Fee Schedule as requiring
prior authorization for payment; or
A prescribed service is not identified in the Medical Fee Schedule
(4)
When the indicators of the Treatment Guidelines are met, no prior authorization is
required.
To complete a prior authorization request, the provider shall concurrently explain the
reasonableness and the medical necessity of the services requested, and shall provide relevant
supporting medical documentation. Supporting medical documentation is defined as documents
used in the provider’s decision-making process to substantiate the need for the requested service
or procedure.
When completing Form WC 188, the ATP shall provide the patient’s information including the
patient’s name, date of injury, date of birth (DOB), carrier claim # (if known), and the date the
request is being submitted to the carrier.
Date of Injury:
Patient’s DOB:
Carrier Claim #:
Date Sent:
Patient’s Name: Last
First
MI
Insurance Carriers/Agents providing this Form may complete the information in the relevant
boxes as part of their standard template (see example below). For the purpose of this form, an
Agent is an entity or person who has responsibility and authority to discuss and approve the
request.
Insurance Carrier’s/Agent’s Name:
Address: Number and Street
City
State
Zip Code
Telephone Number:
Fax Number:
Example:
ABC Healthcare
100 Standard Blvd.
Denver
CO
80203
Telephone Number:
303-123-4567
Fax Number:
303-123-5678
The following boxes must be completed identifying the ATP requesting the prior authorization
request:
Provider’s Name:
Telephone Number:
Fax Number:
NPI/FEIN:
Address: Number and Street
City
State
Zip Code
For all requests, please specify the services being requested, all known appropriate billing codes
and the final diagnoses.
1
Instructions for Form WC 188
Authorized Treating Provider’s Request for Prior Authorization
Prior authorization for payment shall be requested by the authorized treating provider (ATP)
when:
(1)
A prescribed service exceeds the recommended limitations set forth in the
Medical Treatment Guidelines;
(2)
The Medical Treatment Guidelines otherwise require prior authorization for that
specific service;
(3)
A prescribed service is identified within the Medical Fee Schedule as requiring
prior authorization for payment; or
A prescribed service is not identified in the Medical Fee Schedule
(4)
When the indicators of the Treatment Guidelines are met, no prior authorization is
required.
To complete a prior authorization request, the provider shall concurrently explain the
reasonableness and the medical necessity of the services requested, and shall provide relevant
supporting medical documentation. Supporting medical documentation is defined as documents
used in the provider’s decision-making process to substantiate the need for the requested service
or procedure.
When completing Form WC 188, the ATP shall provide the patient’s information including the
patient’s name, date of injury, date of birth (DOB), carrier claim # (if known), and the date the
request is being submitted to the carrier.
Date of Injury:
Patient’s DOB:
Carrier Claim #:
Date Sent:
Patient’s Name: Last
First
MI
Insurance Carriers/Agents providing this Form may complete the information in the relevant
boxes as part of their standard template (see example below). For the purpose of this form, an
Agent is an entity or person who has responsibility and authority to discuss and approve the
request.
Insurance Carrier’s/Agent’s Name:
Address: Number and Street
City
State
Zip Code
Telephone Number:
Fax Number:
Example:
ABC Healthcare
100 Standard Blvd.
Denver
CO
80203
Telephone Number:
303-123-4567
Fax Number:
303-123-5678
The following boxes must be completed identifying the ATP requesting the prior authorization
request:
Provider’s Name:
Telephone Number:
Fax Number:
NPI/FEIN:
Address: Number and Street
City
State
Zip Code
For all requests, please specify the services being requested, all known appropriate billing codes
and the final diagnoses.
1
If Medical Treatment Guidelines have been met and no prior authorization is required, but the
provider still chooses to submit a request, please include:
• An adequate definition or description of the nature, extent, and need for the procedure;
• Identify the appropriate Medical Treatment Guideline application to the requested
service; and
• Document that the indicators in the guidelines have been met.
For all other requests, when prior authorization is indicated, please include:
• Compliance with the general principles of the Medical Treatment Guidelines including
functional goals of treatment; and
Any studies or articles that justify the medical necessity and use of the requested service
or procedure.
If the requestor is attaching supporting documentation, please check the relevant box.
Specify service(s) and billing code(s):
Dx/ICD-10 Codes:
Medical Justification for the requested procedure(s) or for treatment beyond guideline recommendation (Rule 17):
Supporting documentation attached:
If the requested procedure is not identified in the Medical Fee Schedule or does not have an
established value, please include the following documentation:
• Identify and recommend a Medical Fee Schedule code that has an established value and
is reasonably similar to the requested service or procedure;
• Why the recommended similar code value and any dollar value above or below this
procedure is reasonable as requested;
• Any temporary CPT
code for the service, if applicable;
®
• The number of times the service has been performed by the requesting provider;
• Whether the procedure will be performed independent from other services provided or at
the same surgical site or through the same surgical opening; and
• Time, effort and equipment necessary to provide the service.
If the requestor is attaching supporting documentation, please check the relevant box.
If establishing reimbursement for By Report (BR) or Relativity Not Established (RNE), please describe required
procedure; give recommended payment based on requested code(s) with justification for payment:
Supporting documentation attached:
The ATP or representative must print his/her name and sign the request, attesting to submission
of this form to the appropriate carrier/agent.
2
Insurance Carriers/Agents providing this form may complete the information in the relevant
boxes as part of their standard template (see example):
I certify that this request was sent to:
Submitted by:
 Mail
[Insert carrier/agent/self-insured here]
 Fax:
Ordering Provider or Representative:
(
)
 Email:
[Print Name]
Signature:
Date:
Example:
I certify that this request was sent to:
Submitted by:
 Mail
ABC Healthcare
 Fax:
Ordering Provider or Representative:
(303) 123-5678
 Email:
[Print Name]
parmailbox@abc.com
Signature:
Date:
The payer shall respond to all providers requesting prior authorization within seven (7) business
days from receipt* of the provider’s completed request. The duty to respond to a provider’s
written request applies without regard for who transmitted the request. Failure of the payer to
timely comply** shall be deemed authorization for payment.
* Date of receipt of the bill may be established by the payer’s date stamp or electronic
acknowledgement date; otherwise, receipt is presumed to occur three (3) business days after the date
the bill was mailed to the payer’s correct address.
** See full requirements in Rule 16-11(A), (B), and (E)
The payer may respond to the prior authorization request by completing the bottom grayed
portion of WC 188 or through their own system-generated letter as long as all required
information is provided.
A denial of authorization must be completed in
Payer Response to Medical Service/Procedure request:
accordance with the procedures as outlined in Rule 16-
11 (A) Contest of Prior Authorization for Non-Medical
Reasons or 16-11 (B) Contest of Prior Authorization for
Granted (please provide authorization code):
Medical Reasons and the payer must clearly identify
whether granting or denying prior authorization for the
services requested on this form.
The payer may comply with this rule by either citing or attaching the applicable Medical
Treatment Guideline(s). A denial for medical reasons shall include an explanation of the specific
medical reasons for the contest, including the name and professional credentials of the person
performing the medical review and a copy of the medical reviewer’s opinion. A certificate of
mailing of the written contest must be sent to the provider and parties.
Medical reasons for denial(s) of any request for prior authorization require a medical opinion/review in accordance
with Rule 16-11 (B) and Rule 17, applicable Treatment Guidelines to be attached to this response form.
I certify that copies of the approval/denial were completed and sent to the health care provider, the injured worker,
and the injured worker’s legal counsel on the date below:
3
Clear Entire Form
COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
DIVISION OF WORKERS’ COMPENSATION
AUTHORIZED TREATING PROVIDER’S REQUEST FOR PRIOR AUTHORIZATION
Please fill out all required information, as missing information may delay your request.
Date of Injury:
Patient’s DOB:
Carrier Claim #:
Date Sent:
Patient’s Name: Last
First
MI
Insurance Carrier’s/Agent’s Name:
Address: Number and Street
City
State
Zip Code
Telephone Number:
Fax Number:
AUTHORIZED TREATING PROVIDER REQUESTING PRIOR AUTHORIZATION
Provider’s Name:
Telephone Number:
Fax Number:
NPI/FEIN:
Address: Number and Street
City
State
Zip Code
AUTHORIZATION REQUESTED/STATEMENT OF MEDICAL NECESSITY
Specify service(s) and billing code(s):
Dx/ICD-10 Codes:
Medical Justification for the requested procedure(s) or for treatment beyond guideline recommendation (Rule 17):
Supporting documentation attached: 
If establishing reimbursement for By Report (BR) or Relativity Not Established (RNE), please describe required procedure; give
recommended payment based on requested code(s) with justification for payment:
Supporting documentation attached: 
I certify that this request was sent to:
Submitted by:
 Mail
 Fax:
Ordering Provider or Representative:
(
)
 Email:
Signature:
Date:
The self-insured employer or employee’s insurance carrier shall respond with their required
Date Received:
information (noted in the grey shaded areas) within seven (7) business days from receipt of
the provider’s completed request.
A denial of authorization must be completed in accordance
Payer Response to Medical Service/Procedure request:
with the procedures as outlined in Rule 16-11(A) Contest of
Prior Authorization for Non-Medical Reasons or 16-11(B)
Contest of
Prior Authorization for Medical Reasons and the payer must
Granted (please provide authorization code):
clearly identify whether granting or denying prior authorization
for the services requested on this form.
Medical reasons for denial(s) of any request for prior authorization require a medical opinion/review in accordance with Rule 16-11(B)
and Rule 17, applicable Treatment Guidelines to be attached to this response form.
I certify that copies of the approval/denial were completed and sent to the health care provider, the injured worker, and the injured
worker’s legal counsel on the date below:
By: (Print Name)
Title:
Signature:
Date:
WC 188 Rev. 03/18
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