Revised 1/8/10

 

Date:

Ordering Provider's Full Name
Street Address
City, State, Zip Code

RE: Patient Name:
Claim Number:
Injury Date:
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.

[UR Agent] has received your request for approval of health care services. After review of this request, a determination as to the medical necessity and reasonableness for the requested medical services cannot be made due to a lack of information. Please provide the following information:

For Prospective and Concurrent Utilization Review, the requested information must be provided within seven (7) business days from the date of this request. If the information is not received by the seventh (7 th) business day, the initial utilization reviewer will forward the request along with all existing medical information to the Medical Director or school to school reviewer. The reviewer will render a determination based on existing information.

For Retrospective Utilization Review, the information must be provided within thirty (30) days from the date of this request. If the information is not received by the thirtieth (30th) day, the initial utilization reviewer will forward the request along with all existing medical information to the Medical Director or school to school reviewer. The reviewer will render a determination based on existing information.

Sincerely,

 

UR Agent Name/Title

CC: Injured Worker
Adjuster Name/Company