Compliance Corner
In California, when utilization review results in a denial or modification of treatment, state law provides a mechanism for challenging the decision. So, how does such a dispute find resolution? As Simply Research subscribers know, the Golden State has procedures for that.
Basic Rule
A request for independent medical review of a utilization review decision that denies or modifies a medical treatment request must be filed by an eligible party by mail, facsimile, or electronic transmission with the Administrative Director, or the Administrative Director’s designee, within 30 days of service of the written utilization review determination issued by the claims administrator under section 9792.9.5(e).
Medical Treatment Utilization Schedule
If the utilization review decision only denies or modifies a medical treatment request for a drug listed on the MTUS Drug List, the request for independent medical review must be filed by the eligible party within 10 days of service of the written utilization review decision.
Which Form?
A request for independent medical review must be made on the Application for Independent Medical Review, DWC Form IMR, and submitted with a copy of the written decision denying or modifying the request for authorization of medical treatment. At the time of filing, the employee shall concurrently provide a copy of the signed DWC Form IMR, without a copy of the written decision denying, or modifying the request for authorization of medical treatment, to the claims administrator.
Eligible Parties
A party eligible to file a request for independent medical review includes:
(1) The employee or, if the employee is represented, the employee’s attorney. If the employee’s attorney files the DWC Form IMR, the form must be accompanied by a notice of representation or other document or written designation confirming representation.
(A) A parent, guardian, conservator, relative, or other designee of the employee pursuant to Labor Code section 4610.5(j).
(B) The physician whose request for authorization of medical treatment was denied or modified may join with or otherwise assist the employee in seeking an independent medical review. The physician may submit documents on the employee’s behalf pursuant to section 9792.10.5 (b) and may respond to any inquiry by the independent review organization.
(2) A provider of emergency medical treatment pursuant to Labor Code section 4610.5(h)(4).
Expedited Review
If expedited review is requested for a utilization review decision eligible for independent medical review, the Application for Independent Medical Review, DWC Form IMR, shall include, unless the initial utilization review decision was made on an expedited basis, written certification from the employee’s treating physician with documentation confirming that the employee faces an imminent and serious threat to his or her health as described in section 9792.6.1(j).
Timelines
(1) If, at the time of a utilization review decision, the claims administrator is also disputing liability for the treatment for any reason besides medical necessity, the time limitation for the employee to submit an application for independent medical review shall not begin to run until the claims administrator serves a notice to the employee stating that the dispute of liability has been resolved.
(2) If the claims administrator provides the employee with a written utilization review determination modifying or denying a treatment request that does not contain the required elements set forth in section 9792.9.5(e) at the time of notification of its utilization review decision, the time limitations for the employee to submit an application for independent medical review shall not begin to run until the claims administrator provides the written decision, with all required elements, to the employee.
Appeals
(1) Nothing in this section precludes the parties from participating in an internal utilization review appeal process on a voluntary basis provided the employee and, if the employee is represented by counsel, the employee’s attorney, have been notified of the timeframes in which to file an application for independent medical review. Any request by the injured worker or treating physician for an internal utilization review appeal process must be submitted to the claims administrator within 10 days after the receipt of the utilization review decision.
(2) A request for an internal utilization review appeal must be completed, and a determination issued, by the claims administrator within 30 days after receipt of the request. If the utilization review decision only denies or modifies a medical treatment request for a drug listed on the MTUS Drug List, the internal utilization review appeal must be completed, and a determination issued, by the claims administrator within 10 days after receipt of the request under. An internal utilization review appeal shall be considered complete upon the issuance of a final independent medical review determination under section 9792.10.6(e) that determines the medical necessity of the disputed treatment.
(3) Any determination by the claims administrator following an internal utilization review appeal that results in a modification of the requested medical treatment shall be communicated to the requesting physician and the injured worker, the injured worker’s representative, and if the injured worker is represented by counsel, the injured worker’s attorney according to the requirements set forth in section 9792.9.5(e). The Application for Independent Medical Review, DWC Form IMR, that accompanies the written decision letter under section 9792.9.5(e)(7), must indicate that the decision is a modification after appeal.
