Department of Industrial Accidents
Utilization review conducted after services have been rendered.
1. Written request for utilization review (UR) of 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. Initial licensed reviewer commences the review 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, 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. Retrospective reviews shall be completed within twenty (20) 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.
7. 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 twenty (20) business days from receipt of 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.
8. 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 twenty (20) business days from receipt of the UR request.