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Utilization Review

A Utilization Review is a process of determining whether the treatment prescribed by your doctor is medically necessary to treat your work-related injury. During this process, the treatment will be either approved, modified, or denied. Our Sacramento workers’ compensation attorneys have been advising people on the Utilization Review process since its creation in 2003. Our attorneys can help you understand how the utilization process works, the different types of Utilization Reviews, and what to do if your treatment has been denied after a Utilization Review. Contact us at Sacramento Workers’ Compensation Attorneys, P.C. to understand more about Utilization Reviews.

How does the Utilization Review process work?

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 without meeting certain criteria.

If your doctor believes treatment is necessary, they submit a request for authorization to the insurance company and the review process begins. The request for authorization is sent to the reviewer who makes a decision 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.

What are the different types of Utilization Reviews?

Prospective review: A prospective review or pre-authorization is a Utilization Review conducted before requesting medical services. Prospective 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 from the request for authorization. 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 from the request for authorization. However, written decisions must be sent within 24 hours of the reviews 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 request for authorization.

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

What happens if your treatment is denied after a Utilization Review?

If your treatment is denied after a Utilization Review, you can appeal the decision. 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.

What can you do?

Understanding the Utilization Review process can be confusing. Our attorneys at Sacramento Workers’ Compensation Attorneys, P.C. will help you understand everything about a Utilization Review. We help you understand how the utilization process works, the different types of Utilization Reviews, and what to do if your treatment has been denied after a Utilization Review. Contact us a Sacramento Workers’ Compensation Attorney today for more information.