Bulletin No. 68-06
November 30, 2006

Division of Workers' Compensation posts form for utilization review complaints

The CA Division of Workers' Compensation (DWC) has posted a new form for reporting utilization review complaints on its Web site. The form provides a standard way for medical providers and injured workers or their representatives to lodge complaints about violations of utilization review rules with the division.

"This new form helps ensure the division gets the information it needs to investigate complaints," said DWC Executive Medical Director Anne Searcy. "It should also serve to remind the community that the division intends to enforce its regulations."

Utilization review (UR) is the process used by employers or their insurance companies to determine if treatment prescribed for an injured worker is medically necessary. All employers or the insurance companies handling workers' compensation claims 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.

The UR process is governed by Labor Code section 4610 and regulations written by the DWC, which are contained in Title 8, California Code of Regulations, sections 9792.6 et seq.

Additionally, the division has proposed penalties for those violating UR standards. The DWC released a second draft of its UR penalty regulations last week for public comment. The draft regulations are posted at http://www.dir.ca.gov/dwc/DWCPropRegs/UREnforcementRegulations/UR_EnforcementRegulations.htm and comments will be taken until Dec. 12.

Medical providers, injured workers or others who believe that UR is not being done in accordance with the state's regulations can use the newly posted form to report their complaint to the DWC.

The form is available on the forms page of the DWC Web site at http://www.dir.ca.gov/dwc/forms.html. Injured workers may also benefit from reading the UR fact sheet (A) at http://www.dir.ca.gov/dwc/iwguides.html.