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Industrial Commission of Arizona
Protection of life, health, safety, and welfare of Arizona's workforce

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  • Home
  • Agency Information
    • About Us
    • Commissioners
    • Director's Office
    • Legislation
      • Arizona Statutes
      • Arizona Rules
    • Meetings
      • All Public Meetings
      • Commission Meeting Agendas
      • Meeting Minutes
  • Divisions
    • Administration
      • Accounting
      • Human Resources, Special Services and MIS
      • Self-Insurance and Tax Office
    • Administrative Law Judge (ALJ) Division
    • ADOSH
      • Boiler Section
      • Elevator Section
      • Occupational Safety and Health (OSHA / ADOSH)
      • Research & Statistics (BLS)
    • Claims Division
    • Labor Department
    • Legal Division
    • Medical Resource Office (MRO)
    • Special Fund Division
  • News and Events
    • Public Notices
    • News and Events
  • Resources For
    • Resources for Employees
    • Resources for Employers
    • Resources for Insurers
    • Resources for Medical Providers
    • Resources for ICA Community
  • How Do I
  • Online Services
    • Forms
    • Self Service Center
    • ICA Community
  • Payment Portal
  • OMBUDSMAN
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  • MRO REQUEST FOR ADMINISTRATIVE PEER REVIEW FORM

MRO REQUEST FOR ADMINISTRATIVE PEER REVIEW FORM

This form is to be used by Medical Providers, Injured Employees and Injured Employee representatives. This form is to be used when a Medical Provider or Injured Employee (1) disagrees with the Payer’s reconsideration decision, or (2) the request for preauthorization is supported by the Guidelines, and Payer’s initial decision denied the request, or (3) a Payer failed to communicate its decision on a request for preauthorization within 10 business days. Note. If a Payer obtains an Independent Medical Examination (IME) that serves as the basis for his/her decision, then review of that decision must be requested by the injured employee under A.R.S. § 23-1061(J).

This form may be submitted in mail, electronically, or by fax (using contact information provided on the MRO website). 

For more information, contact (602) 542-4308 or (602) 542-6731. 

Official Website of the State of Arizona

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Contact Us:

Phoenix Office
800 W. Washington Street
Phoenix AZ 85007
602-542-4661

 

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Contact Us:

Tucson Office
2675 E. Broadway Blvd
Tucson AZ 85716
520-628-5188

 

 

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