Department of Industrial Accidents
The injured employee/representative and ordering practitioner have a right to request an appeal of an adverse determination.
All requests for appeal level review must be received by the utilization review (UR) agent no later than thirty (30) days from the date of receipt of the notice of adverse determination. Appeal determinations must be rendered by a licensed reviewer who was not involved with the initial adverse determination and is of the same school as the ordering practitioner.
Appeal requests should be in writing. However, the appeal may be initiated verbally. If the appeal is verbal, the UR agent should request the ordering practitioner or injured employee/representative to follow‑up with a written appeal request. If the injured employee/representative or ordering practitioner fails to comply, the UR agent should send a written confirmation of the appeal request.
The person appealing the adverse determination has the right to speak to the appeal level reviewer. A discussion between the ordering practitioner and school to school reviewer is encouraged at the appeal level; however it is not mandated when not requested by the ordering practitioner. If the appealing party requests to speak to a school to school reviewer, the UR agent is required to make a good faith effort to facilitate a discussion between the appealing party and same school reviewer. The UR agent should contact the ordering practitioner on the day the request is received and provide a minimum of at least four time periods during the two (2) business day appeal period that the school reviewer will be available to speak to the ordering practitioner. Each of those time periods should be at least two hours in duration. The dates and times must be provided in writing to the ordering practitioner, and every effort must be made by the UR agent to ensure that the ordering practitioner is afforded an opportunity to speak to the school reviewer.
Unless the ordering practitioner agrees to a different time period, all communication and the determination must be completed within two (2) business days from the date of receipt of the appeal request for prospective and concurrent reviews; and twenty (20) days for retrospective reviews. When the ordering practitioner is not available to speak with the school reviewer in the two (2) business day time period, the UR Agent may ask the ordering practitioner if he/she would like to withdraw the appeal request and resubmit it at a later date within the thirty (30) day time period. If the ordering practitioner does withdraw the appeal, it is the ordering practitioner's responsibility to timely request the appeal again in writing within the thirty (30) day period.
The ordering practitioner should provide any additional medical information which may assist the reviewer at the appeal level.
If the ordering practitioner or injured employee disagrees with the appeal level determination, a claim may be filed with the Department of Industrial Accidents.
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