Department of Industrial Accidents
R equest for Additional Medical Information
I. Prospective and Concurrent Reviews
1. Written request for utilization review (UR) of proposed or ongoing medical services received by UR agent.
2. The day the medical request is received; UR staff enters demographic information, confirms compensability, and forwards all information to the initial utilization reviewer to complete the case record. If compensability is not confirmed, the UR agent should inform the injured employee and the ordering provider in writing that UR will not proceed because of a compensability issue. The parties should be instructed to contact the claim adjuster.
3. Initial licensed reviewer conducts the review and determines the need for additional medical information. The reviewer contacts the ordering provider and requests specific medical information which is necessary to complete the review. The request letter shall inform the ordering provider that the information must be provided within seven (7) business days from the date of request. Request letter shall also inform the ordering provider that if the requested medical information is not received by the seventh (7 th) business day, the medical director or school to school reviewer will issue a determination based on existing medical information. The request may be denied for lack of information.
4. If medical information is not provided by the end of the seventh (7 th) business day, the initial reviewer forwards the UR request and existing medical information to the medical director or school to school reviewer. The medical director or same school reviewer will render a determination based on existing medical information, and treatment guideline if applicable. An adverse determination may be rendered for lack of information. UR agent issues prospective/concurrent review determination within two (2) business days from the seventh (7 th) business day. All determination letters shall set forth the treatment/procedure allowed or denied; start and end dates if applicable; the treatment guideline; clinical rationale; and name and professional degree of reviewer. Adverse determination letters shall include information as to the appeal process.
5. If the requested medical information is received by the initial reviewer, the reviewer conducts the prospective or concurrent review. If the proposed treatment is appropriate and reasonable, the reviewer renders an approved determination within two (2) business days from receipt of the information. If the initial licensed reviewer is unable to approve the request after consulting Treatment Guidelines, the reviewer forwards the medical information to the school to school reviewer. A determination shall be rendered within two (2) business days from receipt of the requested information.
II. Retrospective Reviews
Follow Procedure for Request for Additional Medical Information of Prospective and Concurrent Reviews. However, the ordering provider is afforded thirty (30) days from the date of request to provide the information. Retrospective review determinations shall be rendered within twenty (20) business days from receipt of the requested information. If the ordering practitioner does not provide the requested information within thirty (30) days, within two (2) business days thereafter, the UR agent shall provide written notification of the determination rendered by the medical director or school to school reviewer.
UR case notes should reflect the date medical information was requested and the date the information was received.