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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.
Final utilization review regulations
Final utilization review penalty regulations
- Utilization review complaint form
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Note: If you want to save this form to your computer and email it to the DWC Medical Unit, you MUST use the Word version. The PDF 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
- Answers to frequently asked questions about utilization review (UR) for claims administrators.
Submitted utilization review plans version 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.
| Jun. 18, 2008 | California Division of Workers’ Compensation posts results of utilization review investigations on its Web site 
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| Jun. 27, 2007 | Division of Workers' Compensation advises claims administrators to continue to pre-approve certain requests for treatment Penalty regulations not intended to drive all requests for treatment to a formal utilization review process |
| Jun. 15, 2007 | Medical treatment guideline regulations approved |
| Jun. 7, 2007 | Utilization review enforcement regulations approved |
| May 8, 2007 | The California Division of Workers' Compensation files final medical treatment guideline regulations with the Office of Administrative Law |
| Apr. 26, 2007 | The California Division of Workers' Compensation files final regulations for utilization review enforcement with the Office of Administrative Law |
| Mar. 29, 2007 | Division of Workers' Compensation issues second 15-day notice of revisions to proposed medical treatment guideline regulations |
| Mar. 21, 2007 | Division of Workers' Compensation issues fourth 15-day notice of revisions to proposed utilization review enforcement regulations |
| Mar. 9, 2007 | Division of Workers' Compensation issues third 15-day notice of revisions to proposed utilization review enforcement regulations |
| Mar. 2, 2007 | Division of Workers' Compensation medical guideline advisory committee will begin work March 19 to supplement treatment guidelines |
| Feb. 7, 2007 | Division of Workers' Compensation issues 15-day notice of revisions to proposed utilization review enforcement regulations |
More news archives can be found on the DWC newsline page at www.dir.ca.gov/dwc/dwc_newsline2007.html.
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 ACOEM, 25 Northwest Point Boulevard, Suite 700, Elk Grove Village, IL, 60007 (http://www.acoem.org, 847-818-1800).
November 2008