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 process claims administrators use to ensure 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. How will they decide whether to approve my treatment request?

A. Claims administrators’ UR programs must use guidelines under California’s medical treatment utilization schedule (MTUS) to determine if a treatment is medically necessary. Doctors providing care to injured workers are also supposed to make treatment recommendations based on the MTUS.

MTUS guidelines are based on scientifically-proven treatments that are generally accepted by the national medical community. 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. It also outlines processes that must be followed if a treatment is not addressed within the MTUS.

More information on the MTUS is available on the DWC website.

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. UR applies to future medical treatment awards unless a settlement was reached otherwise. The law requiring UR went into effect on Jan. 1, 2004. It applies to all medical treatment being given, even if you received your award before Jan. 1, 2004.

Q. Will the claims administrator tell me if they decide to delay, modify, or deny my doctor’s request to treat me?

A. Yes. The claims administrator, or its contracted UR vendor, must tell you, your attorney if you are represented, and your doctor, in writing and state why they are delaying, changing, or denying your treatment.

Q. Who can determine (approve, modify, or deny) whether I can get 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 modify (change) your treatment can only be made by a licensed doctor who understands the type of injury or illness you have and the treatment being recommended.

Q. How soon after my doctor recommends treatment will I hear back from the Claims Administrator?

A. For accepted claims with no liability issues, the claims administrator (or its contracted UR vendor) must generally conduct utilization review and make a decision within 5 business days of the date your doctor submitted the treatment request. They must alert the physician who recommended the treatment within 24 hours of making the decision which must be followed by written notice to you (or your representative) and the requesting physician within 2 business days of the decision, or, if you are an inpatient when the treatment request is made, then 24 hours. (This timeframe assumes the requested treatment is not urgent and that it is not for treatment that has already been given.)

If additional information, tests, or an exam is necessary in order to make a decision, the claims administrator can extend the time it takes to respond to the treatment request. If additional information is required, the claims administrator can have up to 14 days to respond. If additional exams or tests are required, the claims administrator can have up to 30 days to respond.

Q. What if my doctor requests treatment that I need urgently?

A. Your doctor may request “expedited review” if they feel that you are facing imminent and serious threat to your health, including the potential loss of life, limb, or other major bodily function.

Q. What is expedited review?

A. Expedited review refers to a claims administrator’s legal obligations to review a treatment request within a shorter timeframe than usual due to a serious and immediate threat to your health. When there is an immediate threat to your health, it means that waiting for a decision to be made in the normal time frame could harm your life or health, or could permanently risk your ability to fully recover. A serious threat to your health means the possible loss of life, limb, or other major bodily function.

Q. How long does an expedited review take?

A. For expedited reviews, the claims administrator must make a decision within 72 hours from when they receive the information they need to make a determination of medical necessity. If your condition is so serious that 72 hours is too long, they must make the decision sooner.

Q. Can the claims administrator stop my treatment if I’m in the hospital (or some other in-patient facility)?

A. The claims administrator can’t stop treatment recommended by your doctor until they talk to your doctor and come to an agreement about what to do.

Q. What if I disagree with the claims administrator’s decision?

A. If UR denies or modifies a treating physician's request for medical treatment because it determines that the treatment is not medically necessary, you can appeal that decision through a process called Independent Medical Review (IMR).

Along with the written determination letter that denied or modified your requested treatment, you will receive a filled-out but unsigned IMR application and addressed envelope. If you disagree with the decision and want to challenge it, you must sign and mail this form, along with a copy of the UR decision letter, in the envelope to begin the IMR process. But do not wait too long to send in your IMR application because there is a time limit on it. To determine the deadline for sending in your IMR application, carefully read the UR decision letter, which should contain that information. 

Please visit the IMR FAQ page for more detailed information about the process, eligibility and deadlines, as well as a link to the IMR application form.

Q. Is there any way to help make UR go smoothly?

A. At the time of making a treatment request, your doctor should include documentation that supports the request under the Medical Treatment Utilization Review (MTUS) guidelines. (For example, if a treatment is not recommended under the guidelines unless another treatment was first tried and failed, then your doctor should be sure to include that information.) UR works best when your doctor stays in contact with the claims administrator’s doctor throughout the process. And if the claims administrator’s doctor asks for more information, your doctor should respond promptly.

Q. What if the required time for responding to my treatment request has passed 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 (DOR) to proceed to an expedited hearing with the Workers’ Compensation Appeal Board in your district office. When a claims administrator has failed to meet the appropriate utilization review deadline, a judge may determine whether the treatment is medically necessary or not.

District offices have Information and Assistance (I&A) officers who help injured workers navigate the workers’ compensation system. An I&A officer may provide further help or information on filing a DOR. To locate a district office, click here.  

April 2024