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What is a workers’ compensation utilization review in California?

On Behalf of | Dec 5, 2019 | Workers' Compensation |

Residents who have an injury or illness that results in an inability to work will take some solace in the protection accorded them through workers’ compensation benefits. Still, there are certain aspects of the workers’ compensation process that might be unfamiliar. That includes the utilization review (UR). Understanding what a UR is and how it can affect the case is essential.

The employer or claims administrator will have a UR to assess the treatment the worker might need and decide if it is medically required. There are guidelines that the state has set up to assist with coming to this determination.

In California, there is a medical treatment utilization schedule (MTUS) that will detail the types of treatment that are known to help the injuries and illnesses. These will be specific to the injury or illness the worker suffers from.

If a doctor recommends a treatment that does not fall into MTUS, it must be based on scientific proof and generally viewed as valid by the medical community. A course of treatment can be approved by anyone who is handling a claim.

If there is a denial or a change to the treatment, it must be done by the doctor. In some cases, a doctor will recommend a certain treatment and the claims administrator will conduct a UR. The review will be conducted by the claims administrator.

A decision will be made within five days of the date the treatment was requested by the doctor. This can be extended to 14 days if additional information is needed. There can be reviews within 30 days if the doctor has already done the treatment and there is a UR.

For people who are hospitalized when the doctor requests treatment, it is possible for there to be an expedited review. This happens when the failure to provide immediate treatment will place the worker in danger of a worse outcome. The expedited review takes 72 hours, but it can be done faster in extreme circumstances. If there is a disagreement with the decision made by the claims administrator, there can be an independent medical review (IMR).

After a work accident, people might be concentrating on their health and getting treatment and not be aware of the various steps necessary to maximize their workers’ compensation benefits. A part of that is the utilization review.


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