1. DWC

Utilization review

Utilization review (UR) is the process used by employers or claims administrators to review treatment to determine if it is medically necessary. All employers or their workers' compensation claims administrators 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 which must be based on the medical treatment guidelines.

The UR process is governed by Labor Code section 4610 and regulations written by the CA Division of Workers' Compensation (DWC), which lay out timeframes and other rules for conducting UR. The rules, contained in Title 8, California Code of Regulations, sections 9792.6 et seq, also require UR plans to be filed with the DWC administrative director.

Additionally, the DWC has promulgated regulations that provide for penalties to apply when claims administrators and UR companies don't follow UR rules. The UR penalty regulations, found in Title 8, California Code of Regulations, sections 9792.11 - 9792.15, provide an enforcement mechanism to ensure utilization reviews are conducted in compliance with UR regulations.

Who has a UR program on file with DWC?

Submitted utilization review plans
These groups have filed UR plans with the DWC (please note that the list does not contain the names of individual employers that might be covered by these plans).

Utilization review claims organizations (UROs)

• List of terminated UROs
• List of UROs with no clients

UR Investigations

• UR investigation results

UR-related complaints

• Utilization review complaint form
• Unless exempted, UR plans who modify or deny treatment requests were required to obtain URAC accreditation on July 1, 2018. Accreditation-related complaints may be filed with URAC at https://www.urac.org/contact/file-a-grievance/.

Resources

• Online physician education courses now available
  DWC offers free online education courses providing continuing education credits for physicians, QMEs, chiropractors, and nurses. Current offerings include the use of the Medical Treatment Utilization Schedule (MTUS) and tips for Qualified Medical Evaluators (QME).

• Frequently asked questions for claims administrators (FAQs)
• Frequently asked questions for injured workers (FAQs)
  
• Utilization review regulations
• Labor Code section 4610

March 2022