The Sedgwick prior authorization form is a one-page “Utilization Review Authorization Request” that your treating provider faxes to Sedgwick before scheduling certain treatments under a workers’ compensation claim. Your provider can pull the form from Sedgwick’s viaOne provider portal or request a copy by calling the utilization review line at 866-286-0281, then fax the completed form with supporting medical records to 877-922-7236.1Pennsylvania Workers’ Compensation Association. Sedgwick Prior Authorization Form
Where To Get the Form
Providers who already have a viaOne Self-Service account can log in and access claim documents and forms directly.2Sedgwick. viaOne Self-Service Portal New providers register through viaOne Express, which asks for a Tax ID, a claim number, and an Internal Control Number (ICN) from an Explanation of Review (EOR) issued within the last two years.3Sedgwick. viaOne Express for Providers – New User Registration If your provider’s office doesn’t use the portal, calling the UR line at 866-286-0281 gets them a copy by fax or email.1Pennsylvania Workers’ Compensation Association. Sedgwick Prior Authorization Form
What Goes on the Form
The form is short, but every field has to be right. A missing or mismatched code is the quickest way to a denial that has nothing to do with whether the treatment itself is appropriate. The required fields are:
- Patient name and Sedgwick claim number, matching the original injury report.
- The treating provider’s federal Tax ID.
- ICD-10 diagnosis codes describing the injury or condition.
- Five-digit CPT or HCPCS procedure codes for each treatment being requested.
Every code must line up with the patient’s medical record. If the ICD-10 code on the authorization request doesn’t match the diagnosis documented in the chart, the reviewer will flag the discrepancy and deny the request on administrative grounds before anyone looks at the clinical question. Double-check each entry against the current records before anything leaves the fax machine.1Pennsylvania Workers’ Compensation Association. Sedgwick Prior Authorization Form
What To Attach
The form is really a cover sheet. What drives the decision is the clinical documentation stapled behind it. Without those records, the reviewer has nothing but procedure codes, and codes alone don’t explain why a patient needs a particular treatment right now.
Attach recent office visit notes describing the current condition, diagnostic imaging reports such as MRIs or X-rays, and physical therapy progress logs if the patient has already gone through conservative care. The attachments should establish two things: the severity of the condition and the fact that less intensive treatment has either been tried or is clearly inadequate. Each document should be current and tied directly to the body part or condition on the workers’ compensation filing. Old notes from unrelated visits won’t help and can slow the review down.
When the request is for something beyond routine care, such as surgery after months of physical therapy, the attached notes should give a clear timeline showing that the patient worked through standard care first and that the requested procedure is the logical next step.
How To Submit It
Fax is the primary submission method. The form itself directs providers to fax the completed request and all supporting records to 877-922-7236.1Pennsylvania Workers’ Compensation Association. Sedgwick Prior Authorization Form Providers with viaOne access can upload documents through the portal instead. Either way, keep the confirmation page or upload receipt. Once the UR department receives the package, a coordinator checks that the required fields are filled in and assigns a tracking number.
If something is missing, Sedgwick sends back a notice listing exactly what it still needs. That isn’t a denial, but it resets the clock. Every round trip adds days, so the first submission should be treated as the only one.
How the Request Is Reviewed
Sedgwick’s clinical reviewers, usually a nurse or physician, measure the request against evidence-based guidelines such as the Official Disability Guidelines, and in California, the Medical Treatment Utilization Schedule.4MCG. Treatment Guidelines – ODG5Cornell Law Institute. California Code of Regulations Title 8 Section 9792.21 – Medical Treatment Utilization Schedule The underlying standard is that the treatment be reasonably required to cure or relieve the effects of the work-related injury. Treatments that are experimental, unrelated to the documented injury, or unsupported by the guidelines get flagged.
When a request falls outside standard protocols, a peer-review physician may call the treating provider to discuss the rationale. This peer-to-peer conversation is where your provider can explain patient-specific circumstances the guidelines don’t cover. If the initial reviewer appears to lack the relevant clinical background, that’s worth raising on the call or saving for an appeal.
Decision timelines depend on the state and on urgency. For standard, non-urgent requests, state rules commonly give Sedgwick up to 15 calendar days from receipt, with a possible 15-day extension if more information is needed.6Illinois Workers’ Compensation Commission. Summary of Utilization Review Guidelines and Timeframes For urgent medical situations, the window shrinks to 72 hours or less. Sedgwick then sends a written notice to the provider and the injured worker stating whether the service is approved, modified, or denied.
If the Request Is Denied
A denial is not the end. Workers’ compensation systems build in multiple layers of review, and the denial letter itself will list the specific reason and the next step. Read it closely. If the denial was based on missing information rather than a medical-necessity dispute, resubmitting with the missing records is faster than filing an appeal.
If the issue is medical necessity, the general path looks like this:
- Internal reconsideration. The treating provider asks Sedgwick to look again, usually by submitting additional clinical evidence or requesting a peer-to-peer review. Some states require this step in writing within 30 days of the denial.
- Independent medical review. Many states offer an external review by a physician who had no part in the original decision. In California, this is called Independent Medical Review (IMR), and the injured worker has to file within the deadline on the denial letter.7Department of Industrial Relations. Independent Medical Review (IMR)
- Administrative hearing. If the dispute still isn’t resolved, the injured worker can file a formal claim with the state’s workers’ compensation board, which may send the case to an administrative law judge.
Emergencies and Billing
Prior authorization is for planned treatment. When a work injury requires emergency care, the treatment comes first and the paperwork follows as a retrospective authorization request. The review standard is the same, but the provider carries more risk, because a retrospective denial means the service was already performed and may go unreimbursed. If you receive emergency treatment on a workers’ comp claim, make sure your provider files the retrospective request promptly.
One point worth knowing as the injured worker: if Sedgwick denies the request, the provider generally cannot bill you for the treatment. Workers’ compensation rules prohibit balance billing injured workers for amounts above what the insurer pays or for services denied through utilization review.8Ohio Bureau of Workers’ Compensation. Rule 4123-6-07 Balance Billing Prohibited If a provider’s office asks you to pay out of pocket for workers’ comp treatment, that’s a signal something is off. Payment disputes belong between the provider and the carrier.