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Procedures for conducting prospective, concurrent and retrospective utilization reviews

Instruction on carrying out utilization reviews on Massachusetts workers' compensation cases.

1. Prospective review procedure

Utilization review conducted prior to the delivery of the requested medical service. Prospective reviews include the initial review conducted prior to the start 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 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 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 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 2 business days from receipt of the UR request.

 

2. Concurrent review procedure

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 told to contact the claim adjuster.

3. Initial licensed reviewer begins 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/Protocols to determine medical necessity and appropriateness of the proposed treatment/protocol. 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 1 day prior to the start/implementation date for the ongoing care if the ordering practitioner contacts the UR agent at least 3 business days prior to the start/implementation date. If the ordering practitioner fails to contact the UR agent at least 3 business days prior to the start/implementation date for ongoing care, the UR agent shall issue the concurrent review determination within 5 business days from the date the concurrent review request was received.

If the initial licensed reviewer is unable to approve the request after consulting Treatment Guidelines/Protocols, 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 needs to state 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 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.

3. Retrospective review procedures

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 won't proceed because of a compensability issue. The parties should be instructed to contact the claim adjuster.

3. Initial licensed reviewer starts 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, the initial licensed reviewer consults the MA Treatment Guidelines/Protocols to determine medical necessity and appropriateness of the proposed treatment/protocol. If the reviewer determines that MA Treatment Guidelines/Protocol don't apply or don't 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 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/Protocols, the reviewer forwards the request for a school-to-school review. The same school reviewer conducts the medical review and renders a determination within 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 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 20 business days from receipt of the UR request.

4. Request for additional medical information

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 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 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 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 2 business days from the seventh 7 th business day. All determination letters shall set forth the treatment/protocol 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 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 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 30 days from the date of request to provide the information. Retrospective review determinations shall be rendered within 20 business days from receipt of the requested information. If the ordering practitioner does not provide the requested information within 30 days, within 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.

5. Appeal procedure

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 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 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 2` 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 2 business days from the date of receipt of the appeal request for prospective and concurrent reviews; and 20 business days for retrospective reviews. When the ordering practitioner is not available to speak with the school reviewer in the 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 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 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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