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Can I Fight a Coventry Notification of Non Certification?3 minute read

If you are reading this article, you have probably had some medical treatment recommended by your doctor in a workers compensation case.  Then you received a letter or an email from Coventry notifying you that the medical treatment was not certified.

Your first question was probably, “What in the world does this mean?” Most of these letters have a lot of official sounding language in them about:

  • Your work injury and medical treatment;
  • Some medical guidelines that say when treatment is appropriate; and
  • Attempts by a doctor to contact your doctor to discuss the treatment that is recommended

Can you still get the treatment that your doctor recommended?In this article, I am going to discuss what these letters mean in Georgia workers’ compensation cases and how you might get the medical treatment you need.

Case manager with doctorWhat is Coventry?

Coventry is a large company that does a lot of workers’ compensation business.  When you received the “Notification of Non Certification” from Coventry, you have encountered that company in the utilization review or peer review process.

The basic idea of utilization or peer review is to have a medical provider review the recommendations made by another medical provider.  In this review, they try to determine whether these recommendations are appropriate.

If you received the “Notification of Non Certification”, Coventry has probably conducted a prospective utilization review of the medical care recommended by your doctor or other medical provider.

What does all that language in the Notification of Non Certification mean?

The Notification of Non Certification and other utilization review documents generally contain information explaining why the recommended treatment is certified or not certified.

This letter from Coventry probably had some information from a doctor and a nurse about the treatment that was recommended.  It may have referred to the Official Disability Guidelines or some other set of guidelines.

This language supports the non-certification decision.  It states the reasons for why Coventry is not certifying the treatment or testing recommended by your doctor.

If I received the “Notification of Non Certification”, does this mean that the insurance company is denying my treatment?

Not necessarily.  Coventry is generally separate from the insurance company handling in your case.

Most of these non certification letters or other utilization review documents will have some sort of language indicating that your claims examiner or adjuster will make the decision about whether to approve treatment.  They may say something like, “The claims handler or representative will make the final decision about approval of medical treatment”.

Many insurance adjusters do have authority to override utilization review determinations.  Whether they will use that authority to override the utilization review denial is a separate question though.

Often, most insurance companies will refuse to authorize medical treatment if the utilization review indicates that the treatment should not be certified or approved.  But, I have had many times where a conversation with the adjuster has gotten the treatment authorized.

If the insurance company denies my medical treatment, what can I do about it?

Denial of medical treatment by insurance companies is one of the most frustrating parts of Georgia’s workers’ compensation system.  After you have suffered an injury, you just want to get better.  When the insurance company delays and denies your medical treatment, you cannot get better.

You can take steps to fight back.  This article I wrote provides some information about how you can overcome medical treatment denials and get the treatment you need.

Often, you may have to convince an adjuster to provide the treatment you need.  If the adjuster refuses, you probably will need to request a hearing.  A workers compensation judge can order the insurance company to pay for the medical treatment you need.

This can be very tricky.  If the insurance company delays or denies your medical treatment. you should strongly consider a consultation with a workers compensation attorney to find out what options you have.

What if I have other questions about workers compensation?

Georgia’s workers compensation system can be very confusing.  You have to worry about getting the treatment you need and paying your bills while also worrying about not missing any deadlines that could cause you to lose your right to receive workers compensation benefits.

If you have questions, I would recommend that you try to get answers.  To find out more about how to schedule a time to talk to me about your workers compensation questions, just read this short article.

Jason Perkins is an attorney who specializes in representing injured workers.  He regularly publishes videos and write blog articles about Georgia’s workers compensation system and issues that are important to injured workers and their families.

To be notified of Jason’s new workers compensation videos, subscribe to his Georgia Workers Compensation Video Series channel on YouTube by clicking the subscribe button below.

Brittney-lee orourkeBrittney-lee orourke
05:23 18 Feb 22
Amazing! Jason and his team were very helpful and had the best communication by far. Walked me though every step with great detail and had answers for any question I had. They handled my case better then I could imagine, it was a weird case and they stayed on top of it and kept me updated every step of the way! Highly recommend this Team! Thanks so much to Jason and his Awesome team!-Brittney
China JonesChina Jones
18:58 08 Feb 22
I absolutely love this group of attorneys, when I was at my lowest they did everything they could to help me get justice for my injury. I believe if I were to have never picked my phone up and called the amazing group that helped me I definitely would not have received my idea of rights. If you have an issue and are just not sure please understand that they will help you, stay in contact, answer any question you have, and for sure get you the justice you deserve I thank them from the bottom of my heart and I will definitely refer them to anyone who has been hurt because they most definitely care about their work and clients.
Luv LocsLuv Locs
16:08 15 Jan 22
The entire law office was attentive and responsive to all of my concerns dealing with my workers compensation case.
moombimoombi
21:14 02 Jan 22
If you must get a lawyer involved, you’d do well to work with Jason Perkins and his team at Perkins Studdard Law.They were thorough in gathering information and in sharing all the steps in the workers comp process specific to my case. Jason and the team were responsive to my bevy of questions and concerns.I appreciated the informative videos and consultations provided by Jason over video meetings and multiple phone calls.I hope I’m never injured on the job again. However, if I am and if my employer responds as my previous employer did, I’ll contact Perkins Studdard Law immediately to handle the case.
Dana BessDana Bess
23:57 10 Dec 21
Everyone at Perkins Studdard was kind and professional. They were always extremely responsive and answered all questions that I had and followed up to make sure I had an understanding of what was going on along with emailing videos to explain every step of my case so I would know what to expect and be prepared. Jason is a very genuine person and I trusted him with my case. He answered so many questions for me even before I retained him as my WC lawyer. I highly recommend him and his associates at Perkins Studdard.
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