California’s Utilization Review Process Explained

There is growing interest in ensuring that anyone who receives medical care through workers’ compensation claims deserves it. It’s a harsh reality in California. If you have suffered an injury at work, you likely just want to ensure your losses are covered by the coverage employers are required to maintain under law. However, this process is not always easy to navigate. A key component of it is the Utilization Review, or UR. It is the process of determining medical necessity and medical causation. Your case will go through this process.

What Is Utilization Review?

Utilization Review is the process that employers and claims administrators use to look closely at the treatment given to a patient. The goal is to determine if that treatment is considered medically necessary. Under the state’s law, it is a requirement for employers or workers’ compensation claims administrators to have a UR program. The program itself reviews the recommended treatment from a medical professional and approves it. The state has very specific medical treatment guidelines to govern these decisions.

You can review the details of the UR program through the State of California’s Department of Industrial Relations. This includes information about Labor Code section 4610 and the details from the California Division of Workers’ Compensation which are listed in Title 8, California Code of Regulations, sections 9792.6 et seq.

What Happens During the Process?

You are hurt on the job and visit a medical provider. The treating physician will submit a request for treatment from the insurance adjuster or third-party administrator of the workers’ compensation plan. This is done through the Request for Authorization form. The adjuster can approve the medical care. If not approved, the process moves to the UR program – which is a separate entity from the workers’ compensation administrator.

The UR company will then have five business days to review the request for care. This statutory response time is important, but it does require that all applicable medical records to be submitted. As long as the requests meet with the medical treatment guidelines created by the state, the care moves forward. Most often, there is a call between the UR physician and the treating doctor to make the decision about care provided.

If a denial occurs, the doctor may recommend that the patient obtain an Independent Medical Review, a process of appeals. The IMR physician will then review the medical records, the UR’s physician’s decision, and the doctor’s recommendations to make a final decision to approve or deny the care. If the physician denies the care from here, there are steps to appeal this decision, but generally, it is hard to get these decisions overturned.

How Can an Attorney Help You During the UR Process?

It’s important that individuals seeking care get that care. Yet, it is also important to understand the UR process as well as what medical treatment guidelines are. When you work with our legal team, we’ll help you to be proactive with medical doctors at all levels. We’ll also work closely with you to provide any evidence or details that may help make your case. We support your medical doctor’s recommendations through the UR process.

And, of course, if you are suffering from a workers” compensation loss, you need to ensure your claims are managed properly. Denials from this type of claim are common, but they are rarely the final decision. Many times, our attorneys will work with our clients to ensure they get the care they need even if they have been denied previously through the UR process or through the IMR process. We represent you throughout the workers’ compensation hearing and every step of the medical review process.

Don’t Face Workers’ Compensation Claims Alone

Because UR is complex and because you just want support for your workers’ compensation claims, we highly advise you to work closely with our legal team. At Appel Law Firm LLP, we understand this process and will work with you and your medical team to ensure your needs are met. Keep in mind that UR doesn’t have to be complex if you have a workers’ compensation attorney by your side. Contact our team for a free consultation through our online form, or call us at 925-938-2000.

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