Utilization Review (UR) is the evaluation of medical care services that are recommended by the authorized treating physician and provided to an injured employee. This evaluations is done to ensure that the services are necessary, appropriate and likely to be effective.
The medical necessity of a treatment recommended by an authorized treating medical provider is disputed by the insurance adjuster; and, in instances required by the workers’ compensation statutes or medical fee schedule (e.g., hospital admissions, physical or occupational therapy, chiropractic care, clinical psychological treatment).
What does UR do?
UR provides for the review of medical procedures recommended by the authorized treating physician as well as the pre-admission review of all hospital admissions, except for emergency services. This review occurs prior to the procedure being performed to ensure that the procedure is appropriate, necessary and likely to be effective. The decision reached by the utilization review agent can only address medical necessity, not causation and/or compensability. Initial decisions regarding causation and compensability must be made by the adjuster or Third Party Administrator. The UR Agent conducting the review services for the employer must be registered with the Bureau of Workers’ Compensation and the Tennessee Department of Commerce and Insurance.
Who decides if the recommended treatment is appropriate?
Recommended treatment can be denied only by an Advisory Medical Practitioner. An adjuster cannot deny a recommended treatment as not being medically necessary. Denials must be accompanied by a utilization review report that gives the reasons for denial and the contact information for the utilization review physician.
Medical treatment may be approved by any of the following:
- Insurance adjuster
- Registered nurse
- An Advisory Medical Practitioner, which is an actively TN-licensed practitioner, who is board-certified and in the same or similar general specialty as the authorized treating physician.
An approval of the treatment by the utilization review agent is final and not subject to appeal. Denials of recommended treatment must be accompanied by a utilization review report that gives the reasons for denial and contact information for the utilization review physician.
Appealing the decision
A decision to deny treatment can be appealed. Denials must be accompanied by an Utilization Review Appeal Form (Form C-35A) so the injured worker, their attorney and treating physician are informed of the proper procedure to request an appeal.
After a denial, the injured worker, their attorney or treating physician has thirty (30) calendar days from receipt to appeal the utilization review decision to the Bureau at the address listed on the form. After a complete medical record is received, the Bureau of Workers’ Compensation’s Medical Director, or his/her designee, will determine if he/she agrees with the insurance carrier’s utilization review denial. If the Medical Director, or his/her designee, disagrees with the utilization review decision, an order for the treatment recommended by the authorized treating physician will be issued.The fee charged for this review must be paid by the employer or insurance carrier.
Are their time limits involved for this review?
Yes. The adjuster has three (3) business days after being notified of the recommended treatment to approve the treatment or send the recommendation to its utilization review agent. The utilization review agent has seven (7) business days to make a decision on the recommended treatment and notify all parties of the decision.
If the utilization review agent does not possess all necessary information in order to render the utilization review determination, the agent must request additional information, in writing, from the authorized treating physician. That physician must comply with the request within five (5) business days of receipt of the written request. The number of business days is extended until the utilization review agent receives the necessary information or until the five (5) business day timeframe expires, whichever occurs first.
Ensuring fairness in the process
An employer, insurer, third party administrator, or UR Agent who is found to have violated the UR rules may be subjected to a penalty of not less than $100 nor more than $1,000 per violation. The Bureau may also institute a temporary or permanent suspension of the right to perform utilization review services for workers’ compensation claims, if the utilization review agent has established a pattern of violations.