DWC Form RFA "Request for Authorization" - California

What Is DWC Form RFA?

DWC Form RFA, Request for Authorization, is a legal document filled out by the treating physician of the employee with a work-related injury or illness to request authorization of special medical treatment, services, and procedures.

An RFA Form must be given to the claims administrator or authorized agent of the utilization review organization in charge of the utilization review process. The claims administrator then reviews the request and determines if this treatment to an industrial injury or illness is medically necessary and appropriate. It is necessary to obtain preauthorization of non-emergency services by identifying recommended treatments and attaching documentation that substantiates the need for the treatment.

This form was released by the California Division of Worker's Compensation, a component of the California Department of Industrial Relations. The latest version of the form was issued in February 2014 with all previous editions obsolete.

You can download a fillable California RFA Form through the link below.

ADVERTISEMENT

Download DWC Form RFA "Request for Authorization" - California

930 times
Rate
(4.5 / 5) 45 votes
PRINT CLEAR
State of California, Division of Workers’ Compensation
REQUEST FOR AUTHORIZATION
DWC Form RFA
Attach the Doctor’s First Report of Occupational Injury or Illness, Form DLSR 5021, a Treating Physician’s
Progress Report, DWC Form PR-2, or equivalent narrative report substantiating the requested treatment.
New Request
Resubmission – Change in Material Facts
Expedited Review: Check box if employee faces an imminent and serious threat to his or her health
Check box if request is a written confirmation of a prior oral request.
Employee Information
Name (Last, First, Middle):
Date of Injury (MM/DD/YYYY):
Date of Birth (MM/DD/YYYY):
Claim Number:
Employer:
Requesting Physician Information
Name:
Practice Name:
Contact Name:
Address:
City:
State:
Zip Code:
Phone:
Fax Number:
Specialty:
NPI Number:
E-mail Address:
Claims Administrator Information
Company Name:
Contact Name:
Address:
City:
State:
Zip Code:
Phone:
Fax Number:
E-mail Address:
Requested Treatment (see instructions for guidance; attached additional pages if necessary)
List each specific requested medical services, goods, or items in the below space or indicate the specific page number(s)
of the attached medical report on which the requested treatment can be found. Up to five (5) procedures may be entered;
list additional requests on a separate sheet if the space below is insufficient.
Other Information:
Diagnosis
ICD-Code
Service/Good Requested
CPT/HCPCS
(Frequency, Duration
(Required)
(Required)
(Required)
Code (If known)
Quantity, etc.)
Requesting Physician Signature:
Date:
Claims Administrator/Utilization Review Organization (URO) Response
Approved
Denied or Modified (See separate decision letter)
Delay (See separate notification of delay)
Requested treatment has been previously denied
Liability for treatment is disputed (See separate letter)
Authorization Number (if assigned):
Date:
Authorized Agent Name:
Signature:
Phone:
Fax Number:
E-mail Address:
Comments:
DWC Form RFA (Effective 2/2014)
Page 1
PRINT CLEAR
State of California, Division of Workers’ Compensation
REQUEST FOR AUTHORIZATION
DWC Form RFA
Attach the Doctor’s First Report of Occupational Injury or Illness, Form DLSR 5021, a Treating Physician’s
Progress Report, DWC Form PR-2, or equivalent narrative report substantiating the requested treatment.
New Request
Resubmission – Change in Material Facts
Expedited Review: Check box if employee faces an imminent and serious threat to his or her health
Check box if request is a written confirmation of a prior oral request.
Employee Information
Name (Last, First, Middle):
Date of Injury (MM/DD/YYYY):
Date of Birth (MM/DD/YYYY):
Claim Number:
Employer:
Requesting Physician Information
Name:
Practice Name:
Contact Name:
Address:
City:
State:
Zip Code:
Phone:
Fax Number:
Specialty:
NPI Number:
E-mail Address:
Claims Administrator Information
Company Name:
Contact Name:
Address:
City:
State:
Zip Code:
Phone:
Fax Number:
E-mail Address:
Requested Treatment (see instructions for guidance; attached additional pages if necessary)
List each specific requested medical services, goods, or items in the below space or indicate the specific page number(s)
of the attached medical report on which the requested treatment can be found. Up to five (5) procedures may be entered;
list additional requests on a separate sheet if the space below is insufficient.
Other Information:
Diagnosis
ICD-Code
Service/Good Requested
CPT/HCPCS
(Frequency, Duration
(Required)
(Required)
(Required)
Code (If known)
Quantity, etc.)
Requesting Physician Signature:
Date:
Claims Administrator/Utilization Review Organization (URO) Response
Approved
Denied or Modified (See separate decision letter)
Delay (See separate notification of delay)
Requested treatment has been previously denied
Liability for treatment is disputed (See separate letter)
Authorization Number (if assigned):
Date:
Authorized Agent Name:
Signature:
Phone:
Fax Number:
E-mail Address:
Comments:
DWC Form RFA (Effective 2/2014)
Page 1
Instructions for Request for Authorization Form
Warning: Private healthcare information is contained in the Request for Authorization for Medical
Treatment, DWC Form RFA. The form can only go to other treating providers and to the claims
administrator.
Overview: The Request for Authorization for Medical Treatment (DWC Form RFA) is required for the employee’s treating
physician to initiate the utilization review process required by Labor Code section 4610. A Doctor’s First Report of
Occupational Injury or Illness, Form DLSR 5021, a Treating Physician’s Progress Report, DWC Form PR-2, or equivalent
narrative report substantiating the requested treatment must be attached. The DWC Form RFA is not a separately
reimbursable report under the Official Medical Fee Schedule, found at California Code of Regulations, title 8, section
9789.10 et seq.
Checkboxes: Check the appropriate box at the top of the form. Indicate whether:
This is a new treatment request for the employee or the resubmission of a previously denied request based on a
change in material facts regarding the employee’s condition. A resubmission is appropriate if the facts that
provided the basis for the initial utilization review decision have subsequently changed such that the decision is
no longer applicable to the employee’s current condition. Include documentation supporting your claim.
Review should be expedited based on an imminent and serious threat to the employee’s health. A request for
expedited review must be supported by documentation substantiating the employee’s condition.
The request is a written confirmation of an earlier oral request.
Routing Information: This form can be mailed, faxed, or e-mailed to the address, fax number, or e-mail address
designated by the claims administrator for this purpose. The requesting physician must complete all identifying information
regarding the employee, the claims administrator, and the physician.
Requested Treatment: The DWC Form RFA must contain all the information needed to substantiate the request for
authorization. If the request is to continue a treatment plan or therapy, please attach documentation indicating progress, if
applicable.
List the diagnosis (required), the ICD Code (required), the specific service/good requested (required), and
applicable CPT/HCPCS code (if known).
Include, as necessary, the frequency, duration, quantity, etc. Reference to specific guidelines used to support
treatment should also be included.
For requested treatment that is: (a) inconsistent with the Medical Treatment Utilization Schedule (MTUS) found at
California Code of Regulations, title 8, section 9792.20, et seq.; or (b) for a condition or injury not addressed by
the MTUS, you may include scientifically based evidence published in peer-reviewed, nationally recognized
journals that recommend the specific medical treatment or diagnostic services to justify your request.
Requesting Physician Signature: Signature/Date line is located under the requested treatment box. A signature by the
treating physician is mandatory.
Claims Administrator/URO Response: Upon receipt of the DWC Form RFA, a claims administrator must respond within
the timeframes and in the manner set forth in Labor Code section 4610 and California Code of Regulations, title 8, section
9792.9.1. To communicate its approval on requested treatment, the claims administrator may complete the lower portion
of the DWC Form RFA and fax it back to the requesting provider. (Use of the DWC Form RFA is optional when
communicating approvals of treatment; a claims administrator may utilize other means of written notification.) If multiple
treatments are requested, indicate in comments section if any individual request is being denied or referred to utilization
review.
DWC Form RFA (Effective 2/2014)
Page 2
ADVERTISEMENT

DWC Form RFA Instructions

The employee's treating physician needs to provide the following details in the DWC Request for Authorization:

  1. Specify the type of request. It may be new, expedited (if the employee faces a serious and imminent threat to their health), resubmitted, or written confirmation of a prior oral request;
  2. Add employee information - full name, date of birth, date of injury, number of the claim, and name of the employer;
  3. Identify yourself - full name, practice name, contact name, address, phone number, and e-mail address. Specify your specialty and National Provider Identifier number;
  4. Enter the claims administrator details - the name of the company, contact name, address, phone number, and e-mail address;
  5. List requested medical goods, items, and services. Name the employee's diagnosis, indicate the International Statistical Classification code of the injury or illness, the American Medical Association's Current Procedural Terminology/Healthcare Common Procedure Coding System code, and provide other information about the treatment (duration, frequency, quantity, etc.). Additional requests must be submitted on a separate sheet if you do not have enough space for it in the request;
  6. Sign and date the form.

Once the request is filled out, mail, fax, or e-mail it to the address, fax number, or e-mail address is given to you by the claims administrator. You need to attach Form DLSR 5021, Doctor's First Report of Occupational Injury or Illness, and DWC Form PR-2, Treating Physician's Progress Report. Then the administrator will approve, modify, deny, or delay the request, notify you the requested treatment has already been denied or inform you that the liability for the treatment is disputed within five business days of receipt of the request. The authorized agent will write down their authorization number, name, and contact information, date and sign the form.

Page of 2