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Answers to frequently asked questions about utilization review (UR) for injured workers
In addition to the FAQs below, you may find the DWC’s fact sheets and guides for injured workers useful and can access them at the I&A Unit’s Web page.
Q. What is utilization review (UR)?
A. UR is the program claims administrators use to make sure the treatment you receive is medically necessary. All claims administrators 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.
The state has rules about how UR must be conducted. If you believe the UR company reviewing your doctor's treatment request is not following those rules you can file a complaint with the DWC.
Q. What are the medical treatment guidelines set by the state?
A. California’s medical treatment utilization schedule (MTUS) details treatments scientifically proven to cure or relieve work-related injuries and illnesses. The MTUS lays out treatments that are effective for certain injuries, how often the treatment should be given, the extent of the treatment and other details.
All doctors providing care to injured works and claims administrators’ UR programs must use the MTUS to determine if a treatment is medically necessary.
Q. Where can I look at the MTUS?
Q. What if the treatment my doctor recommends isn’t in the MTUS?
A. Your doctor needs to use other scientifically-based medical treatment guidelines generally accepted by the national medical community to support the recommended treatment. The MTUS provides guidance on what doctors should do to choose appropriate guidelines if the treatment is not in the MTUS.
Q. I was awarded future medical treatment for my work injury. I have a copy of the award. Does UR apply to me?
A. Yes. The law requiring UR went into effect Jan. 1, 2004. It applies to all medical treatment being given, even if you received your award before Jan. 1, 2004.
Q. Who can evaluate the medical treatment my doctor has recommended?
A. 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 doctor who understands the type of injury or illness you have and the treatment being recommended.
Q. What happens when my doctor recommends treatment and the claims administrator does a UR?
A. The claims administrator must do the review and make a decision within five days of the date your doctor requested the treatment. If additional information is needed to make a decision, the claims administrator can have up to 14 days.
Q. What if my doctor has already provided the treatment and the claims administrator does a UR?
A. The review must be done and the decision given to your doctor within 30 days.
Q. What happens if I got treated and the claims administrator says they won’t pay for it? Do I have to pay?
A. Most likely, no. This is a problem your doctor and the claims administrator need to work out.
Q. What if my doctor requests treatment while I am in the hospital?
A. Your doctor may request a regular or “expedited review” while you’re receiving treatment in the hospital.
Q. What is an expedited review?
A. 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.
Q. How long does an expedited review take?
A. 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.
Q. Can the claims administrator stop my treatment if I’m in the hospital?
A. 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.
Q. Will the claims administrator tell me if they decide to change, delay or deny my doctor’s request to treat me?
A. Yes. The claims administrator has to tell you, your attorney if you are represented, and your doctor in writing and state why they are changing, delaying, or denying your treatment.
Q. What if I disagree with the claims administrator’s decision?
A. There are specific timelines you must meet or you will lose important rights. As of July 1, 2013, medical treatment disputes for all dates of injury will be resolved by physicians through the process of independent medical review (IMR). If UR denies or modifies a treating physician's request for medical treatment because the treatment is not medically necessary, you can ask for a review of that decision through IMR.
Along with the written determination letter that denied or modified your requested treatment, you will receive an unsigned but completed IMR form and addressed envelope. If you disagree with the decision, you must sign and send this form in the envelope to start the IMR process.
Q. Is there any way to help make UR go smoothly?
A. UR 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.
Q. 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?
A. If your doctor has not been able to get a response from the claims administrator, you should file a declaration of readiness to proceed to expedited hearing. A claims administrator who fails to meet the appropriate deadline for a utilization review cannot object to the doctor providing the requested treatment.
Q. If my doctor's request for treatment is not approved, what can I do?
A. If you agree with the treatment requested by your doctor and the treatment is denied after being reviewed through the UR process, the dispute will be resolved through IMR, for all dates of injury.