Utilization Review

In the state of California, the workers' compensation utilization review process is used by the workers' compensation insurance company or the employer of an injured worker to decide if a worker's treatment is medically necessary. Utilization reviews can be done by claims adjusters, non-physician reviewers, or physician reviewers.

Following the utilization review, if the medical treatment request is approved, the California Labor Code does not allow the employer to decline appropriate reimbursement for the treatment specified. This includes payment for medical services, even those which the employer later determines were provided by an ineligible physician. This does not mean, however, that the administrator may not have the legitimate right to dispute certain parts of the bill.

Why does California require a utilization review prior to treatment?

Courts have rigorously enforced the process of determining medical necessity and medical causation within California's utilization review process. The court has argued that utilization review has helped to help create consistent medical treatment processes for injured workers in the state.

Requesting treatment after an injury

Doctors must follow regulations established under 8 CCR § 9792.6(b). These regulations identify how a medical care provider must requests treatment, diagnostic tests or other medical services for an injured worker in the state of California.

For instance, according to LexisNexis, "all requests must be made in writing within 72 hours of the doctor's First Report of Occupational Injury or Illness (form DLSR 5021), the Primary Treating Physician Progress Report (DWC form PR-2), or in a narrative report that contains the same information required in the PR-2 form."

Utilization review decision can it be postponed

Under some conditions the utilization review can be delayed (i.e. the claims administrator disputes liability for the occupational injury of other reasons not related to medical necessity). If the claim's administrator decides to delay the utilization review they must send notification to the requesting physician, the injured worker, and the worker's lawyer (if applicable).

Notice for the delay must contain the RFA date; the description of the proposed medical treatment, information about why the liability for the injury is disputed; and how the employee can resolve the dispute.