Utilization Review

Utilization Review (UR) is the evaluation of medical care services for the treatment provided to an injured worker. This evaluation is done to ensure that the services are necessary, appropriate, and likely to be effective. 

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The Process

If an authorized treating physician’s recommended treatment cannot be approved by the adjuster, the adjuster may seek an opinion from another physician through a utilization review organization. The decision reached by the URO agent only addresses medical necessity (not causation and/or compensability). When recommended treatment is not certified (approved), they are reported back to the injured worker and the physician. Either can appeal the denial. Denials must be based on the Official Disability Guidelines (ODG) by MCG which are independent, evidence-based guidelines for treating common work injuries. 

Required Use of UR

The following treatments are required to be sent to UR: 

• In-patient hospital admissions
• Non-emergency ground and air ambulance services
• When the adjuster cannot approve the treatment

Requirements for a Denial by the Utilization Review Organization 

Recommended treatment can be denied only by a Utilization Review Physician who is of the same or similar specialty and licensed in the state of Tennessee. Denials must be accompanied by a utilization review report that gives the reasons for denial and the name and credentials of the utilization review physician.  

Appealing Denied Treatment 

1. Receive Denial Letter & C-35A. If the URO denies a physician’s recommended treatment, the URO (or the employer’s insurance adjuster) is required to provide the injured worker and the treating physician the denial letter and a pre-filled Form C-35A that can be sent either to the insurer for reconsideration or to the Bureau of Workers’ Compensation.
   • The injured worker, their attorney or treating physician has thirty (30) calendar days from receipt of the denial letter to appeal the utilization review decision to the Bureau of Workers’ Compensation at the address listed on the form.
2. If appealed to the Bureau and the necessary medical records are received, the Bureau's Medical Director will make a determination to approve, modify, or deny the treatment. This decision is final for administrative purposes.
3. The fee charged by the Bureau is paid by the insurer.

Deadlines

• The adjuster has four (4) business days after being notified by the provider of the recommended treatment to approve the treatment or send the recommendation to its utilization review organization (URO).  
• The URO has seven (7) business days to make a decision on the recommended treatment and notify all parties of the decision.  
  • If the URO does not possess all necessary information in order to render the utilization review determination, the agent may request additional information, in writing, from the authorized treating physician.
  • That physician shall send the request within five (5) business days of receipt of the written request.
  • The number of business days is extended until the URO receives the necessary information or until the five (5) business day timeframe expires, whichever occurs first. 

Rules Violations

An employer, insurer, third party administrator, or UR Organization who is found to have violated the UR rules may be subjected to a penalty of not less than $50 nor more than $5,000 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. 

Mediation 

Parties who are not satisfied with the appeal may file for mediation. Reviewing the denial, understanding its reasoning and gathering information might result in agreement. If mediation is not successful, a judge may rule on whether the ATP’s recommended treatment was appropriate.