Revised 1/8/10


Injured Worker Name
Street Address
City/State/Zip Code


RE: Claim Number:
Injury Date:
UR File Number:

Dear [Injured Employee 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 been requested by [Name of Company] to perform utilization review of the medical treatment provided or proposed by your health care provider to determine if the services are medically necessary and appropriate.

You should have received a Utilization Review identification card from the workers' compensation insurer's claims office when your injury was reported. If you have not received the card from [Insurance Company name], please contact them at [Insurance Company Phone Number] to request one.

As the injured worker, you or your provider, are required to contact the Utilization Review department prior to seeking medical care for a work-related injury. The UR department can be reached at 1-800-[ ] between the hours of 9:00 a.m. and 5:00 p.m., Monday through Friday.

In case of an emergency, seek emergency medical care. You or your representative should contact the Utilization Review department within 24 hours after the emergency treatment to request approval for the service.

The Utilization Review process is to determine the medical necessity and appropriateness of treatment and is not an approval or guarantee for payment of medical services. Only the insurance carrier or claims representative can approve payment.

If at any time an injured employee, ordering provider, or employee representative believes the utilization review agent's conduct to be in violation of the Code of Massachusetts Regulations, 452 CMR 6.00, a complaint may be filed with the Department of Industrial Accidents by contacting the Department at 617-727-4900 to request a UR agent complaint form (133A). A copy of this form is posted on the Department's website at



UR Agent Name/Title

CC: Adjuster Name/Company