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This page, Sample utilization review letters, is offered by
Department of Industrial Accidents

Sample utilization review letters

These are samples of letters that can be used for utilization review.

Sample letters

Sample introductory letter

Approved determination

Adverse determination

Expedited appeal level review notification

Request for additional information

Appeal outcome - approval

Appeal outcome - adverse determination

Withdrawal of appeal

Practitioner certification of active practice

Contact for Sample utilization review letters

Phone

Call Office of Health Policy at (617) 727-4900, Ext. 7310

Address

1 Congress St., Suite 100, Boston, MA 02114

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