This outlines the policies and procedures of the Walmart/Claims Management Inc., North Carolina's Preauthorization Program (hereafter referred to as "the Program") which utilizes GENEX Services, LLC as the Utilization Review Agent.

In accordance with 04 NCAC 10A.1001, all surgeries and all inpatient treatments are subject to the preauthorization process. A request for authorization of any surgery or any inpatient treatments is classified as a "mandatory request" under the Program.

Although North Carolina does not require preauthorization for outpatient services, the Program may perform preauthorization and retrospective reviews at the direction of CMI, the third party administrator of Walmart's workers' compensation claims in North Carolina. This type of request is classified as a "voluntary request" under the Program.

A. Initiation of Initial Preauthorization Request

  1. Requests for preauthorization can be made by workers' compensation health care providers, claimant's attorneys, unrepresented claimants, employers, insurers or third party claims administrators. The preauthorization requests shall be submitted on the Industrial Commission Form 25PR. The form can be obtained on the North Carolina web site at http://www.ic.nc.gov/forms/form25pr.pdf 04 NCAC 10A.1001(k).

  2. The Form 25PR shall be transmitted to GENEX either by email at lakemaryur@genexservices.com or fax to 877-835-2684.

  3. GENEX will send acknowledgement of the request to the requesting entity and insurer/claims administrator within 2 business days of receipt of the Form 25PR. 04 NCAC 10A.1001(k).

  4. GENEX is available for communication via telephone, fax and/or email on a pending request for preauthorization (including Peer Review Physicians) on a continuous basis on every business day (which excludes weekends and holidays) between the hours of 8:00 AM and 8:00 PM Eastern Standard Time. 04 NCAC 10A.1001(e)(2)

  5. After hours communication is accessible via phone mail between the hours of 8:00 PM and 8:00 AM Eastern Standard Time Monday through Friday and weekends & holidays. All calls received after hours will be responded to on the next business day.

  6. All requests for service are registered into the GENEX computer system (CMS) by the GENEX Support Staff who verifies appropriate carrier, claim, and Injured Worker information and forwards the case to the GENEX Non-Physician Reviewer for review. These Reviewers are restricted from reviewing clinical information or making clinical decisions.

B. Initial Review Process by Non-Physician Reviewer (Nurse)

  1. A GENEX Non-Physician Reviewer is a Registered Nurse (RN), Licensed Vocational Nurse (LVN) and/or Licensed Professional Nurse (LPN) who holds a current, unrestricted license in their state of residence.

  2. Upon receipt of the clinical information, the Nurse evaluates the requested services for medical necessity of procedure/treatment and inpatient admissions, duration of care, and appropriateness of services and makes authorization decisions using specified criteria as previously stated. The Nurse has electronic and phone access to consult with an MD/DO or licensed health professional in the same licensure category as the requesting provider.

  3. If the Nurse can authorize the request, she/he will notify the appropriate entities as outlined in section D "Time Frame Requirements."

  4. If the Nurse is unable to authorize the request in its entirety, the request will be forwarded to a Peer Review Physician. Only physicians may modify or deny treatment requests.

  5. No denial is based on a Nurse Review.

C. Review Process by Peer Review Physician

  1. Clinical reviews are conducted by a GENEX Peer Review Physician on all cases where an authorization is not issued through the initial review.

  2. The GENEX Peer Review Physician is a medical doctor, doctor of osteopathy, psychiatry, psychologist, acupuncturist, optometrist, dentist, podiatrist, or chiropractic practitioner currently licensed by North Carolina, South Carolina, Georgia, Virginia or Tennessee and shall hold professional qualifications, certifications, and fellowship training in a like specialty that is at least equal to that of the treating provider who is requesting preauthorization of surgery or inpatient treatment. 04 NCAC 10A.1001(i)

  3. An opportunity for a Peer to Peer discussion is offered to the requesting provider prior to the determination being made. The Peer Review Physician is available to discuss the determination with the requesting provider at 800-382-9163 on any business day between 8:00 AM and 8:00 PM Eastern Standard Time. 04 NCAC 10A.1001(h) In the event the reviewer is unavailable, the requesting physician may discuss the request with another Peer Review Physician who is competent to evaluate the specific clinical issues involved in the medical treatment services. In the event no peer to peer discussion occurred, the Peer Review Physician makes the determination based on the information submitted.

  4. Requests are not denied on the basis of lack of information unless a request to obtain the necessary information from the requesting physician occurs and the requested information is not provided in the appropriate timeframe (outlined in D below) and documentation of the attempt is retained by Genex.

  5. Treatment is not denied on the sole basis that the treatment is not addressed by a guideline.

D. Time Frame Requirements

  1. The first day in counting the timeframe requirement is the day after the receipt of the request.

  2. The request determination shall be communicated to the requesting physician initially by telephone or fax within 7 business days of receipt of the request. 04 NCAC 10A.1001(l)

  3. The communication by telephone/fax shall be followed by written notice and sent to the injured worker and/or the injured worker's representative, the insurer/claims administrator, the requesting physician and facility if known.

E. If a Peer to Peer discussion did not take place, GENEX will accept a phone call from the requesting provider within 24 hours of an adverse determination.

F. Appeal

  1. The requesting provider, claimant's attorney, or unrepresented claimants have the right to submit a request for an appeal no later than the 30th calendar days after the date of the verbal or faxed notification of the modified or adverse determination. This is done by completing the 2nd page of Form 25PR and emailing or faxing along with any additional medical information to lakemaryur@genexservices.com or fax to 877-835-2684.

  2. Appeals will follow the initial workflow as outlined above for initial review.

  3. The appealing party has the right to seek authorization for any denied treatment from the Commission. 04 NCAC 10A.1001(e)(6)

G. Approvals Made by Claims Adjustor

The workers' compensation claims administrator may give approval for any Voluntary pre-authorization requests without formally referring the request to GENEX. The supervisor for Walmart's North Carolina claims administrator is Gwen Kahler (gwen.kahler@cmiw.com). Mailing address is CMI, PO Box 14731 Lexington, KY 40512. Telephone number is 918-331-4500 x 57531. Fax number is 877-219-0832. Normal business hours are 7:00 a.m. to 5:00 p.m. CST.

H. UR Credentialed Peer Review Physician Profiles

Last Name First Name License Type License State Specialty 1 Specialty 2 Specialty 3
Abraham, MD William MD NC Orthopaedic Surgery    
Abraham, MD William MD TN Orthopaedic Surgery    
Adkins, MD Richard MD TN Pain Management Anesthesiology  
Agnew, MD Daniel MD TN Orthopaedic Surgery    
Ayoola, MD Ayodele MD GA Internal Medicine    
Babus, DO Glenn DO TN Pain Management Anesthesiology  
Babus, DO Glenn DO VA Pain Management Anesthesiology  
Bagga, MD Sudhir MD TN Family/General Practice    
Barnett, MD H. Glenn MD TN Neurological Surgery    
Bawden, MD David MD GA Psychiatry    
Beahm, MD Thomas MD TN Plastic Surgery    
Bittinger, MD Marvin MD GA Emergency Medicine    
Blanton, DDS Alan DDS TN Dentistry    
Blecha, MD Richard MD GA Orthopaedic Surgery    
Bluhm, MD Renata MD TN Internal Medicine    
Boortz-Marx, MD Richard MD NC Pain Management Anesthesiology  
Broukhim, MD Benjamin MD TN Orthopaedic Surgery    
Brown, MD Douglas MD VA Orthopaedic Surgery    
Cain, MD James MD GA Orthopaedic Surgery    
Cain, MD James MD TN Orthopaedic Surgery    
Cho, MD Mickey Seong MD GA Orthopaedic Surgery Hand Surgery  
Ciochetty, MD David MD NC Pain Management Anesthesiology  
Clark, DO Sonya DO SC Hand Surgery    
Clark, DO Sonya DO TN Hand Surgery    
Curtis, MD Dale MD GA Emergency Medicine    
Cushman, MD Arthur MD TN Neurological Surgery    
Dawodu, MD Segun MD VA Physiatry Pain Management  
Dorsey, MD E. Richard MD NC Psychiatry    
Ducker, MD Thomas MD GA Neurological Surgery    
Duncan, MD Gary MD TN Neurological Surgery    
Emran, MD Muhammad MD GA Family/General Practice    
Emran, MD Muhammad MD NC Family/General Practice    
Estwanik, MD Joseph MD NC Orthopedics    
Evans, MD John MD NC Orthopaedic Surgery Hand Surgery  
Evans, MD John MD SC Orthopaedic Surgery Hand Surgery  
Fish, MD Daniel MD VA Orthopaedic Surgery    
Ford, MD Kenneth MD TN Orthopaedic Surgery    
Garcia, MD Peter MD GA Orthopaedic Surgery    
Garcia, MD Peter MD TN Orthopaedic Surgery    
Gause, MD Trenton MD TN Orthopaedic Surgery    
Gerstenblitt, MD Daniel MD TN Internal Medicine Occupational Medicine  
Getz, MD Donald MD NC Orthopaedic Surgery    
Gocke, MD Ryan MD NC Orthopaedic Surgery    
Goldman, DO Michael DO TN Family/General Practice Physical Medicine and Rehabilitation  
Goldsmith, MD Gregory MD TN Orthopaedic Surgery    
Greenberg, MD Robert MD TN Orthopaedic Surgery    
Haidak, MD Paul MD TN Plastic Surgery    
Harrop, MD Daniel MD TN Psychiatry Neurology  
Hawthorn, DPM Francis (Bud) DPM TN Podiatry    
Huff, MD Lester MD VA Psychiatry    
Johnson, MD Jeffrey MD TN Internal Medicine    
Kaelin, MD Charles MD TN Orthopedics    
Kaplan, MD Edward MD TN Neurological Surgery    
Kennedy, DO Michael DO SC Orthopaedic Surgery    
Kraft, MD Jerome MD GA Orthopaedic Surgery Hand Surgery  
Kuhn, MD Michael MD NC Orthopaedic Surgery    
Lafavore, MD Paul MD NC Pain Management Anesthesiology  
Lafavore, MD Paul MD TN Pain Management Anesthesiology  
Lazar, MD Alan MD NC Orthopaedic Surgery    
Loubser, MD Paul MD GA Pain Management Anesthesiology  
Lutz, DO Richard DO TN Orthopaedic Surgery    
Mayfield III, MD William MD TN Orthopaedic Surgery Orthopedics  
Mazzella, MD William MD NC Internal Medicine    
McCord, MD David MD GA Orthopaedic Surgery    
McCord, MD David MD NC Orthopaedic Surgery    
McCord, MD David MD TN Orthopaedic Surgery    
McHugh, MD Daniel MD TN Pain Management Physiatry Physical Medicine and Rehabilitation
Pryor, DDS Aaron DDS TN Dentistry    
Ramos, MD Richard MD NC Pain Management Anesthesiology  
Riso, MD Anthony MD GA Pain Management Anesthesiology  
Rush, MD Charles MD TN Obstetrics & Gynecology    
Schroder, MD David MD VA Orthopaedic Surgery    
Shapiro, MD Steven MD GA Orthopaedic Surgery    
Shapiro, MD Steven MD SC Orthopaedic Surgery    
Shaw, DO Erik DO GA Pain Management Anesthesiology  
Shutack, MD John MD VA Neurological Surgery    
Siegel, MD Jerome MD GA Internal Medicine    
Simon, DO Robin DO TN Orthopaedic Surgery    
Smith, DO Glenn DO TN Orthopaedic Surgery    
Somers, MD William MD TN Urology    
Somers, MD William MD VA Urology    
Stefanoski, MD Stevco MD NC Internal Medicine    
Suthar, MD Bhavin MD VA Pain Management Physical Medicine and Rehabilitation  
Szabo, MD Joshua MD NC Orthopaedic Surgery    
Terry, MD Kimberly MD GA Neurological Surgery    
Terry, MD Kimberly MD NC Neurological Surgery    
Terry, MD Kimberly MD SC Neurological Surgery    
Terry, MD Kimberly MD TN Neurological Surgery    
Terry, MD Kimberly MD VA Neurological Surgery    
Walkup, DO Martha DO TN Family/General Practice    
Wilson, MD Terrence MD GA Pain Management Physical Medicine and Rehabilitation  
Winans, MD Robert MD TN Orthopaedic Surgery    
Wood, MD James MD NC Internal Medicine    
Wood, MD James MD SC Internal Medicine    
Ximenes, MD Rey MD TN Pain Management Anesthesiology  
Zadeh, MD Jaffar MD VA Internal Medicine    

Effective: February 4, 2015