What if you disagree with the utilization review (UR) determination for your workers’ compensation claim?

As of July 1, 2013, medical treatment disputes for all dates of injury are resolved by physicians through an efficient process known as Independent Medical Review (IMR).  If utilization review denies, delays or modifies a treating physician’s request for medical treatment because the treatment is not medically necessary, the injured employee can ask for a review of that decision through IMR. The assigned physician reviewer will review relevant medical records and apply recognized treatment guidelines to determine if the requested medical treatment is appropriate for the injured worker’s condition. The IMR process must be completed within 30 days of receipt of all documentation.

The costs of IMR are paid by employers who are required by law to provide injured employees with all medical treatment that is reasonable and necessary to cure or relieve the effects of a work-related injury. The DWC is required to contract with one or more independent medical review organizations (IMROs) to conduct IMR on its behalf.

If IMR denies the proposed treatment and the treatment is provided anyway, then the rendering provider is not entitled to payment under the CA Workers’ Compensation system.