Answers to Your Questions About Utilization Review

Image for Answers to Your Questions About Utilization Review found at: child-Page-Headerblock_43fc211aa77160840509c8fa8cbf1221
Utilization review is the program the claims administrator uses to make sure treatment given to injured workers is consistent with medical treatment guidelines set by the state.

All employers or the claims administrator handling their workers’ compensation claims are required by law to have a utilization review program. This program will be used to decide whether or not to approve medical treatment recommended by your doctor.

What are the medical treatment guidelines set by the state?

Treatment guidelines lay out treatments scientifically proven to cure or relieve work-related injuries and illnesses. They also deal with how often the treatment is given and for how long, among other things. The state of California is currently using the American College of Occupational and Environmental Medicine’s (ACOEM) Practice Guidelines, Second Edition.

Where can I look at the ACOEM guidelines?

Copies of the ACOEM guidelines are available for review at your local Workers’ Compensation Appeals Board (WCAB) office. The Fresno office is located at 2550 Mariposa Mall, Suite 4078, Fresno, CA 93721. The ACOEM guidelines are also available at many law, university and public libraries.

What if the treatment my doctor recommends isn’t in the ACOEM guidelines?

Your doctor needs to use other scientifically-based medical treatment guidelines generally accepted by the national medical community to support the recommended treatment.

I was awarded future medical treatment for my work injury. I have a copy of the award. Does utilization review apply to me?

Yes. The law requiring utilization review went into effect Jan. 1. 2004 and it applies to all medical treatment being given, even if you received your award before Jan. 1, 2004.

Anyone handling claims can approve the treatment recommended by your doctor. However, a decision to deny or change your treatment can only be made by a physician who understands the type of injury or illness
you have and the treatment being recommended.

What happens when my doctor recommends treatment and the claims administrator does a utilization review?

The claims administrator must do the review and make a decision within five days of the date your doctor requested the treatment. If it needs more time, the claims administrator can have up to 14 days. This is called “prospective review” because it’s done before you get the treatment.

What if my doctor has already provided the treatment and the claims administrator does a utilization review?

The review must be done and the decision given to your doctor within 30 days. This is called a “retrospective review”.

What happens if I got treated and the claims administrator says they won’t pay for it? Do I have to pay?

Most likely, no. This is a problem your doctor and the claims administrator need to work out.

What if my doctor requests treatment while I am in the hospital?

Unless your doctor requests an “expedited review”, the review process and timeframe is the same as in the “prospective review”. This is called “concurrent review” because the review is being done while you’re receiving treatment.

What is an expedited review?

This happens when your doctor recommends treatment and says you face a serious threat to your health if you don’t receive it. That could mean possible loss of life, limb or other major bodily function. It could also mean the normal time frame for a decision could harm your life or health, or could permanently risk your ability to recover to the fullest.

How long does an expedited review take?

The claims administrator has 72 hours from when they get the information they need to make the decision. If your condition is so serious that 72 hours is too long, they have to make the decision sooner.

Can the claims administrator stop my treatment if I’m in the hospital?

The claims administrator can’t stop treatment recommended by your doctor until they talk to your doctor and figure out another plan your doctor agrees to. This applies to any concurrent review.

Will the claims administrator tell me if they decide to change, delay or deny my doctor’s request to treat me?

Yes. The claims administrator has to tell you and your doctor in writing, and state why they are changing, delaying or denying your treatment.

What if I disagree with the claims administrator’s decision?

There are specific and strict timelines you must meet or you will lose important rights. You must object to the decision within 20 days of getting it. Once you do that, the claims administrator will give you a qualified medical evaluator (QME) panel request form to submit to the DWC Medical Unit. See Information & Assistance (I&A) guide 2 for instructions on filing the QME request form and pay special attention to the timeline.

Is there any way to help make the utilization review go smoothly?

Utilization review works best when your doctor stays in contact with the claims administrator’s doctor throughout the process. Your doctor must state the reasons for the treatment being requested when making the request. And if the claims administrator’s doctor asks for more information, your doctor should respond.

If I have completed the QME process and the claims administrator is still denying the treatment, what do I do?

You’ll need to see a workers’ compensation judge to get the disagreement resolved. File a declaration of readiness to proceed to expedited hearing to go before a judge. See I&A guide 6 for specific instructions. If you do not have an existing case open at the local WCAB office, you also need to file an application for adjudication of claim (see I&A guide 4), which opens a WCAB case for you.

What if more than 14 days have gone by since my doctor requested treatment and we haven’t heard or received anything from the claims administrator?

If your doctor has not been able to get a response from the claims administrator, file a declaration of readiness to proceed to expedited hearing. See above answer for more details.

If you need one of the I&A guides or other help, call an I&A office or attend a workshop for injured workers. The Fresno I&A office is located at 2550 Mariposa Street, Room 2035, Fresno, CA 93721-2280 and can be reached by phone at (559) 445-5355. You can also get information on local workshops and download the guides from the Web.

The information contained in this fact sheet is general in nature and is not intended as a substitute for legal advice. Changes in the law or the specific facts of your case may result in legal interpretations different than those presented here.