The UR regulations allow an employer to reduce the cost of physician review in UR by designing a "prior authorization" program within the employer's UR plan. The court also held that approving requested treatment without physician review is part of utilization review (UR), and only reviewing physicians may decide to delay, deny or modify requested treatment. The California Supreme Court held that utilization review must be used for every medical treatment request in the California workers' compensation system. Is utilization review required in every case?Ī. The UR time limit for responding to a treatment request begins when the request for authorization (RFA) is first received, whether by the employer, claims administrator or utilization review organization (URO). This program is used to decide whether or not to approve medical treatment recommended by a treating physician.Ī. All employers or their workers' compensation claims administrators are required by law to have a UR program. UR is the process used by employers or claims administrators to determine if a proposed treatment requested for an injured worker is medically necessary. What is utilization review (UR) and why is it used for workers' compensation?Ī. UR and medical provider networks (MPNs) About utilization review: Throughout this FAQ, when citations to Title 8 of the California Code of Regulations are made, they will appear in this format: (CCR, Title 8 § number.) Citations to California's Labor Code appear as: (LC number). In addition to the FAQs below, claims administrators may call 1-80 to hear recorded information on a variety of workers' compensation topics 24 hours a day.Ĭlaims administrators may also call a local office of the state Division of Workers' Compensation (DWC) and speak to the Information and Assistance (I&A) Unit for help during regular business hours.Ĭlaims administrators may find the DWC's fact sheets and guides for injured workers useful and can access them on the I&A Unit's Web page. Answers to frequently asked questions about utilization review (UR) for claims administrators
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