This form is to be used by Medical Providers and Payers. Medical Providers use this form to submit preauthorization request and if applicable, reconsideration request for medical treatment or services for the management of chronic pain or the use of opioids for all stages of pain management. The Medical Provider submits this form directly to the Payer for a decision on their request. Payer may use this form to communicate their decision on initial preauthorization request and reconsideration request by sending to the Medical Provider, with copies of the form being provided to the Payer, and the Injured Employee or their representative. The Payer may use this form to send notice to the Medical Provider that a preauthorization request is incomplete or that an Independent Medical Examination (IME) has been requested. A copy of the MRO-1 form should be submitted by the Medical Provider or the Injured Employee when filing a Request for Administrative Review with the Industrial Commission Medical Resource Office.
For more information, contact (602) 542-4308 or (602) 542-6731