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Understanding the Role of Utilization Reviews in Workers’ Comp Cases

In California, all employers or their workers’ compensation claims administrators must have protocols in place for utilization reviews. A utilization review is the process by which requesting medical treatment is evaluated for the purpose of determining whether it is medically necessary.

After sustaining a workplace injury, a worker may seek treatment at an emergency room, urgent care facility, or doctor’s office. The original treating physician must fill out the first report of occupational injury or illness, which is known as the form DLSR 5021. Later, subsequent treating physicians are required to fill out an RFA form (Request For Authorization), which is used to request authorization for diagnostics, treatments, or other medical services.

Every RFA goes through Utilization Review, a process by which the insurance company determines whether treatment is medically necessary. If UR denies the requested treatment, you must go through the Independent Medical Review (IMR) process. This process requires the injured worker (or their attorney) to file the appropriate paperwork to appeal the denied case.

If an unrepresented injured worker is getting requested treatment denied then they should seek the advice of a workers comp attorney in Santa Clara so that the appeals can be handled properly.

The workers’ compensation guidelines in California state that once a treatment is approved, this authorization cannot be rescinded or modified, even if it is later found that the treating physician is not an authorized provider.

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