Ordering Provider's Full Name
City, State, Zip Code
RE: Patient Name:
UR File Number:
Dear Dr. [Provider's Full Name]:
Massachusetts workers' compensation insurers are required to undertake utilization review of health care services provided to injured workers in accordance with the Utilization Review and Quality Assessment Regulation (452 CMR 6.00). The Commonwealth of Massachusetts Department of Industrial Accidents has approved [UR Agent] to conduct utilization review on Massachusetts workers' compensation claims.
After review of this request, based on the medical information submitted at this time, the following specific treatment (s) and/or service (s) for this patient is Approved only as stated:
Treatment Approved: [procedure/service, frequency, and start and end dates]
Clinical Rationale (include pertinent medical information):
Reviewed By: practitioner name and school of licensure
The requested service meets the established criteria of medical necessity and reasonableness based on the information provided. If additional treatment is required, please forward the request for ongoing/concurrent care in writing at least three (3) days prior to the start/implementation date.
Please contact me if you have any questions regarding this determination at [toll free number].
UR Agent Name/Title
Cc: Injured Worker
Adjuster Name/ Company