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Experiencing a delay in workers’ compensation utilization review decisions? File a complaint



September 08, 2017
Area(s) of Interest: Workers' Compensation Payor Issues and Reimbursement 

The California Division of Workers’ Compensation (DWC) has finalized regulations to ensure that utilization reviews (UR) are conducted in compliance and within specified timeframes (see chart below). The regulations authorize DWC to conduct periodic reviews of all utilization review organizations (URO), including a review of any credible complaints against the organization received by the DWC Administrative Director.

The California Medical Association (CMA) encourages physicians experiencing delays in the receipt of workers’ compensation UR decisions to be diligent in submitting complaints to DWC to highlight organizations that fail to meet the timely review standards. 

 

Type of Utilization Review

 

Response Timeframe

 

Prospective or Concurrent review

 

Response required within five business days from first receipt of a request for authorization (RFA), unless additional medical information is needed.

 

If additional medical information is needed, it must be requested by the URO no later than the fifth business day following receipt of the request.

 

In instances where additional information was requested, the URO has 14 calendar days from the date of receipt of the original RFA to make the decision.

 

Expedited review (within 72 hours of the request) is available when the injured worker faces an imminent and serious health threat or when the normal timeframe for the decision-making process would be detrimental to the injured worker’s life or health or could jeopardize the worker’s permanent ability to regain maximum function.

 

Retrospective review

 

Review must be completed within 30 days of receiving the information required to make a decision.

 

Physicians who find that UR is not being done according to the regulations can complete the UR complaint form and email it with a description of the issue to DWCManagedCare@dir.ca.gov. Indicate “UR Complaint" in the subject line. More information on filing workers’ compensation complaints can be found on the DWC website.

For more information, see CMA On-Call document #7310, "Utilization Review," which provides an overview of California statutes and regulations regarding UR applicable to workers’ compensation insurers and self-insured employers.

CMA On-Call documents are available free to members in CMA’s online Health Law Library. Nonmembers can purchase documents for $2 per page.

Practices that are experiencing UR delays should also contact CMA’s Reimbursement Helpline at (888) 401-5911 or economicservices@cmadocs.org.

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