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What is a utilization review?

On Behalf of | May 3, 2022 | Workers' Compensation

Part of the workers’ compensation process is getting the proper medical treatment. The doctor or other health care professionals you see will have their ideas about what treatments you need, but if you or someone else within the workers’ compensation system feels the course of treatment is not reasonable or necessary, a utilization review can help.

The Pennsylvania Department of Labor & Industry explains a utilization review or UR request begins the process of investigating the medical treatment. You, your employer or the insurer may make the request.

The process

Once someone files a request, it will go to a utilization review organization. The URO will obtain medical records and information to see about the treatment. The URO will compare this to the workers’ compensation records and accepted medical standards. They will then decide on whether the treatment is reasonable and a necessary part of recovery.

The details

The review process takes about 65 days. You can state the URO about your thoughts on the treatment. You will receive a notice that lets you know about your right and how to send the statement. Once the URO makes a decision, you will get notice of either a yes determination or a no determination. A yes means your medical treatment is acceptable, and a no means it is not. The URO may also issue a part yes/part no determination, which should detail which medical care is approved and which is not.

If the URO decides that your treatment is not reasonable, then you will not receive a bill as this is banned under the Workers’ Compensation Act.