Utilization Review

A Utilization Review can be completed by a physician reviewer, non-physician reviewer, or a claims adjuster who works for the Utilization Review company contracted by your workers’ compensation insurance. Non-physician reviewers cannot deny or modify a request for authorization without a physician review or meeting specific criteria.

If your doctor believes treatment is necessary, they submit a request for authorization to the insurance company, and the review process begins. The authorization request is sent to the reviewer, who decides to approve, modify, or deny the treatment requested. Their decision is based on the guidelines stated in the Labor Code Section 5307.27, peer-reviewed scientific journals, expert opinion, and recognized standards of medical care. The decision is sent to you, your doctor, and the insurance company.

Prospective review: A prospective review or pre-authorization is a Utilization Review conducted before requesting medical services. Future studies must be completed within five business days unless there is a request for additional information. In this case, a decision must be made within 14 calendar days of the authorization request. A written decision must be sent within two business days.

Concurrent review: A concurrent review is a utilization review for treatment requested during a hospital stay. Concurrent reviews must be completed within five business days unless there is a request for additional information. In this case, a decision must be made within 14 calendar days of the authorization request. However, written findings must be sent within 24 hours of the review competition.

Retrospective review: A retrospective review is a Utilization Review conducted when medical services have been given, but authorization is not yet received. Retrospective reviews must be completed within 30 days of the authorization request.

Expedited review: An expedited review is a Utilization Review conducted with an injured worker facing a serious health threat. Typical situations where an expedited review is necessary is when an employee faces the loss of life, limb, or primary bodily function. Depending on the employee’s condition, expedited reviews must be 72 hours or less completed within. If an expedited review is needed, the employee’s s physician must check the box for “Expedited Review” on the request for an authorization form.

Prior authorization: Prior authorization is an arrangement by insurance companies to authorize specific treatment for certain conditions without having to submit a request for an authorization form.

You can appeal the decision if your treatment is denied after a Utilization Review. This is called an Independent Medical Review. You can also generally apply for an Independent Medical Review if your treatment is modified. You or your doctor have 30 days from receiving the Utilization Review decision to request an independent medical review.