Department of Industrial Accidents
Utilization review conducted during the patient's course of treatment.
1. Written request for utilization review (UR) of proposed ongoing medical services received by UR agent.
2. The day the UR request is received; UR staff confirms demographic information and documents any changes, confirms compensability, and forwards all information to the initial licensed 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 commences the review by the following business day and documents all required information in the case record. The diagnosis should be provided by the ordering provider.
4. If additional medical information is required, the initial licensed reviewer should follow the procedure for request of additional medical information.
5. If no additional medical information is required, the initial licensed reviewer consults the MA Treatment Guidelines to determine medical necessity and appropriateness of the proposed treatment/procedure. If the reviewer determines that MA Treatment Guidelines do not apply or do not address the condition, a secondary source which is listed in the application should be consulted. If no secondary source addresses the condition, the reviewer notifies the appropriate person designated in the UR application to move forward with the development of an Internal Guideline.
6. Concurrent reviews shall be completed at least one (1) day prior to the start/implementation date for the ongoing care if the ordering practitioner contacts the UR agent at least three (3) business days prior to the start/implementation date. If the ordering practitioner fails to contact the UR agent at least three (3) business days prior to the start/implementation date for ongoing care, the UR agent shall issue the concurrent review determination within five (5) business days from the date the concurrent review request was received. When the start date for ongoing care is to be scheduled, the utilization reviewer has five (5) business days from the date of request to issue the determination.
If the initial licensed reviewer is unable to approve the request after consulting Treatment Guidelines, the reviewer forwards the request for a school to school review. The same school reviewer conducts the medical review and renders a determination; said determination to be issued by the UR agent within the aforesaid time period.
7. Written notification of the determination shall be provided to the ordering practitioner and injured employee/representative. The determination letter 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. Approved determination letters shall inform the ordering practitioner to forward all requests for ongoing/concurrent care at least three (3) business days prior to the start/implementation date. Adverse determinations must be rendered by a school to school reviewer and the letters shall include information as to the appeal process.
8. If additional medical information is required, the initial reviewer should follow procedure for request of additional medical information.