Utilization Review (UR) is the process used by employers or claims administrators to determine if a proposed treatment requested for an injured worker is medically necessary. All employers or their workers’ compensation claims administrators are required by law to have a UR program. This program is used to decide whether or not to approve medical treatment recommended by a treating physician. 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).
A treating physician submits an RFA as follows:
- Prospectively – before providing treatment; UR decision is due 5 business days of receipt of RFA
- Concurrently – currently providing treatment or during an inpatient stay; 5 business days receipt of RFA
- Retrospectively – after providing treatment; 30 calendar days of receipt of RFA
In the case of an immediate and serious threat to the patient’s health, a requesting physician may request expedited utilization review for a prospective or a concurrent RFA and the decision is due within 72 hours of receipt of written information reasonably necessary to make the determination.
If you disagree with the Utilization Review determination, the injured employee can ask for a review through Independent Medical Review (IMR).