Department of Industrial Accidents
Prospective Review

Definition:
Utilization review conducted prior to the delivery of the requested medical service. Prospective reviews include the initial review conducted prior to the commencement of treatment, and the initial review for treatment to a different body part.

1. Written request for utilization review (UR) of proposed medical services received by UR agent.

2. The day the UR request is received; UR staff enters demographic information, 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. The UR introductory letter is sent to the injured employee on the day compensability is confirmed. Introductory letter shall instruct the injured employee to contact the adjuster if the UR card is not received from the insurer.

4. 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.

5. If additional medical information is required, the initial licensed reviewer should follow the procedure for request of additional medical information.

6. If no additional medical information is required, 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.

7. Prospective reviews shall be completed within two (2) business days from receipt of the UR request, and written notification of the determination shall be provided to the ordering practitioner and injured employee/representative. Approved determination letters shall specify approved treatment/procedure; start and end dates if applicable; 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.

8. 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 within two (2) business days from receipt of the request for UR. 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 determinations must be rendered by a school to school reviewer and the letters shall include information as to the appeal process.

9. If the school to school reviewer determines that additional information is required to conduct the review, the reviewer moves to the procedure for request of additional medical information. The letter requesting additional medical information must be sent within two (2) business days from receipt of the UR request.