In the event an injured worker has not relocated out-of-state but is referred to an out-of-state provider for treatment or services not available
within Colorado, the referring provider shall obtain prior authorization from the payer as set forth in Rule 16-9, Prior Authorization, and 16-
10, Contest of a Request for Prior Authorization. The referring provider's written request for out-of-state treatment shall include the
following information:
(a) Medical justification prepared by the referring provider;
(b) Written explanation as to why the requested treatment/services cannot be obtained within Colorado;
(c) Name, complete mailing address and telephone number of the out-of-state provider;
(d) Description of the treatment/services requested, including the estimated length of time and frequency of the treatment/service, and all
associated medical expenses; and
(e) Out-of-state provider’s qualifications to provide the requested treatment or services.
(3) The Colorado fee schedule should govern reimbursement for out-of-state providers.
within Colorado, the referring provider shall obtain prior authorization from the payer as set forth in Rule 16-9, Prior Authorization, and 16-
10, Contest of a Request for Prior Authorization. The referring provider's written request for out-of-state treatment shall include the
following information:
(a) Medical justification prepared by the referring provider;
(b) Written explanation as to why the requested treatment/services cannot be obtained within Colorado;
(c) Name, complete mailing address and telephone number of the out-of-state provider;
(d) Description of the treatment/services requested, including the estimated length of time and frequency of the treatment/service, and all
associated medical expenses; and
(e) Out-of-state provider’s qualifications to provide the requested treatment or services.
(3) The Colorado fee schedule should govern reimbursement for out-of-state providers.
| COLORADO WORKERS COMPENSATION COLLECTION PUBLICATIONS AND INFORMATION FOR MEDICAL PROVIDERS |
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