What Is a Utilization Review in a California Workers’ Comp Case?

 Posted on January 21,2022 in Workers' Compensation

Following a work-related injury, an employee will usually qualify for workers’ compensation benefits. These include medical benefits that will pay for all treatment that is needed, including emergency care, doctor visits, medications, surgery, and long-term or ongoing services such as physical therapy or psychological treatment. The California Division of Workers’ Compensation requires reviews to be performed to ensure that the medical treatment a person receives is necessary to treat their injuries or illnesses. This type of review is known as a utilization review, and workers will need to understand how a review will affect the benefits they receive.

Different Types of Utilization Reviews

All forms of medical treatment that are covered by workers’ compensation are subject to review. A physician or provider will submit a request for authorization (RFA), and this request may be reviewed by a claims adjuster, physician reviewer, or non-physician reviewer. Requests may be fully authorized, partially authorized, or denied. Reviews will generally fall into one of the following categories:

• Prospective review - In many cases, requests will be sent before medical treatment is provided. After an RFA is submitted, a decision must be made within five business days, and the provider must be notified of the decision by phone or fax within 24 hours. If additional information is needed, the provider must be notified within five business days, and a decision must be made within 14 calendar days after the RFA was originally submitted. If the provider is not notified of the decision or a request for additional information within five business days, they will be allowed to proceed with the requested treatment. In some cases, companies may create utilization review plans that provide prior authorization for certain types of treatment, and in these cases, a provider will not be required to submit an RFA.

• Concurrent review - If a person is in the hospital, RFAs may be submitted for treatment during their stay. While the same time frames will generally apply in these cases as for a prospective review, care that is currently being provided should not be discontinued until the provider is notified of a decision to deny coverage, and a physician will be able to make an appropriate plan of care for the injured employee.

• Expedited review - If immediate treatment is needed to address a serious threat to a person’s health, an RFA may ask for an expedited review. In these cases, decisions must be made within 72 hours after the RFA is submitted.

• Retrospective review - For certain types of treatment, an RFA may be submitted after the treatment is provided. Retrospective reviews are generally used for emergency medical care and other forms of treatment that are authorized by an employer within 30 days after an injury occurred. However, a retrospective review is generally not available for most medication prescriptions, non-emergency surgery, diagnostic imaging tests other than X-rays, psychological treatment, or durable medical equipment with a combined total value of $250 or more.

Contact Our Santa Clara County Workers’ Compensation Benefits Lawyers

Following a work injury, you deserve to receive benefits that will fully cover all forms of medical care that are needed. Cramer + Martinez can help you address any issues that may arise during your workers’ compensation claim, including the denial of coverage for medical treatments that may help you recover and return to work. For legal help with your case, contact our Morgan Hill workers’ comp claim attorneys at 408-848-1113 and arrange a free consultation today.

Sources:

https://www.dir.ca.gov/dwc/UtilizationReview/UR_FAQ_InjuredWorker.htm

https://www.dir.ca.gov/dwc/utilizationreview/ur_faq.htm

https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=LAB&sectionNum=4610.