Newsline No. 16-11 printer image Printer friendly
March 2, 2011  

Division of Workers' Compensation posts updated utilization review FAQs on its Web site

The Division of Workers' Compensation (DWC) has updated and posted answers to frequently asked questions (FAQs) about utilization review (UR) on its Web site to help claims administrators, employers and workers better understand UR rules and to address the typical questions that arise in the UR process.

The updated FAQs add in a new topic covering "Requests for authorization" (RFAs). They also offer more detailed information about "Prior authorization," and a new question addressing when a claims administrator may deny a request for authorization without first obtaining a physician review. Other changes include discussion of the UR investigation process, handling RFAs from secondary physicians, agreed medical evaluator/qualified medical evaluator (AME/QME) reports and UR. Additionally, there is new discussion of the California Supreme Court’s 2008 Sandhagen decision, which held that UR is mandatory and is required in every case, but not necessarily for every treatment request.

The FAQs are posted on the DWC's UR Web page.

These FAQs are directed to claims administrators but others may also benefit from reading them. The division also has a UR fact sheet specifically for injured workers.

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