Utilization review

Utilization review (UR) is the process used by employers or claims administrators to review treatment to determine if it is medically necessary. All employers or their workers' compensation claims administrators are required by law to have a UR program. This program is used to decide whether or not to approve medical treatment recommended by a physician which must be based on the medical treatment guidelines.

The UR process is governed by Labor Code section 4610 and regulations written by the CA Division of Workers' Compensation (DWC), which lay out timeframes and other rules for conducting UR. The rules, contained in Title 8, California Code of Regulations, sections 9792.6 et seq, also require UR plans to be filed with the DWC administrative director.

Additionally, the DWC has promulgated regulations that provide for penalties to apply when claims administrators and UR companies don't follow UR rules. The UR penalty regulations, found in Title 8, California Code of Regulations, sections 9792.11 - 9792.15, provide an enforcement mechanism to ensure utilization reviews are conducted in compliance with UR regulations.

UR investigation results

UR rules

• Labor Code section 4610
• Utilization review regulations
• Utilization review penalty regulations
• Notes from April 8 stakeholder meeting
• MTUS information and regulations

UR forms, fact sheets and frequently asked questions (FAQs)

• Utilization review complaint form version version
  Note: If you want to save this form to your computer and e-mail it to the DWC Medical Unit, you MUST use the version. The version cannot be saved to your computer once filled.
  
• Utilization review fact sheet for injured workers
  Respuestas a sus preguntas sobre la revisión de utilización
  
• Frequently asked questions (FAQs)

Who has a UR program on file with DWC?

Submitted utilization review plans version
A list of the groups that have sent actual UR plans to the DWC. The list does not contain the names of individual employers that might be covered by these plans.

Utilization review claims organizations (UROs)

• List of terminated UROs
• List of UROs with no clients

Access to the ACOEM guidelines

Copies of the ACOEM guidelines are available for review at local DWC offices. The ACOEM guidelines are also available at many law, university and public libraries.

For purposes of compliance with the California Code of Regulations, Title 8, division one, chapter 4.5, subchapter one, article 5.5.1, utilization review standards, a claims administrator may make copies of incidental portions of original editions of Occupational Medicine Practice Guidelines, Second Edition, as necessary in connection with a decision to modify, delay or deny services in a specific case under review. Such copies may not be published on the Internet or in any other media. All rights in the Guidelines are reserved by ACOEM.

If you have any questions, please contact:

American College of Occupational and Environmental Medicine (ACOEM)
25 Northwest Point Boulevard, Suite 700
Elk Grove Village, IL, 60007
http://www.acoem.org
(847) 818-1800

October 2011