Newsline No. 50-07
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June 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

The Division of Workers' Compensation (DWC) is reminding claims administrators that they are allowed and encouraged to establish guidelines within their utilization review plans under which certain requests for treatment are not required to go through a formal utilization review (UR) process.

"Ensuring injured workers receive prompt and effective medical care is a top priority," said DWC acting Administrative Director Carrie Nevans. "The UR penalty regulations that were approved earlier this month should not stop adjusters from being selective about which treatment requests need to be reviewed by an off-site UR organization."

The DWC continues to support the establishment of "UR best practices" that allow claims administrators to approve appropriate levels of care for injured workers at the lowest possible levels within the claims organization, without having to send those requests through a third party process.

"In fact, the best way for claim administrators to ensure they meet the timelines for UR is to give adjusters the ability to approve specific treatments within the treatment guidelines," said Nevans. "We are working on a set of frequently asked questions that we will post on our Web site within the next week to assist those with questions about the UR rules."

The UR FAQs will be posted on the division's UR page, located at http://www.dir.ca.gov/dwc/UR_Main.htm. A fact sheet on UR for injured workers, in English and Spanish, along with the UR complaint form and other information, is currently posted there.

The UR regulations, found in the California Code of Regulations, Title 8, section 9792.7 (a) (5) provide that, "Each utilization review process shall be set forth in a utilization review plan which shall contain: (5) A description of the claims administrator's practice, if applicable, of any prior authorization process, including but not limited to, where authorization is provided without the submission of the request for authorization (emphasis added)."

The UR penalty regulations, found in sections 9792.11 - 9792.15, simply provide an enforcement mechanism to ensure utilization reviews are conducted in compliance with UR regulations that have been in place since September of 2005. The UR penalty regulations have not imposed any changes in UR requirements or timelines.

The regulations may be found at http://www.dir.ca.gov/dwc/DWCrulemaking.html.

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