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Special Report: DWC Clarifies Mandatory Use of Request for Authorization Form and Requirements for Complete RFA

Posted by:  Sure S. Log
Topics: Utilization Review Request for Authorization CCR 9792.9.1 narrative report incomplete RFA completed request claims administrator UR process DWC Form RFA CCR 9792.6.1

The utilization review (UR) process begins when a claims administrator receives a completed request for authorization from a treating physician. Under the updated UR regulations that became effective April 1, 2026, California Code of Regulations (CCR), Title 8, § 9792.6.1(u) defines what constitutes a valid "request for authorization," and specifies the conditions under which a request is deemed "completed" for purposes of triggering the UR clock. CCR 9792.9.1(b) addresses the claims administrator's obligations on receipt of a request that does not meet the definition of a completed request.

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Deferring Utilization Review

Posted by:  Sure S. Log
Topics: Utilization Review Request for Authorization RFA LC 4610 threshold issue UR CCR 9792.9.1 retrospective UR UR deferral retrospective review utilization review deferral grounds other than medical necessity

As stated in Labor Code § 4610(a), utilization review is the process a defendant uses to "prospectively, retrospectively, or concurrently review and approve, modify, or deny, based in whole or in part on medical necessity to cure and relieve, treatment recommendations by physicians, ..." (emphasis added). UR is the process to determine only whether a request for treatment is medically necessary. It does not determine other issues.

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Designating Address, Fax Number or Email Address for Utilization Review Purposes

Posted by:  Sure S. Log
Topics: Division of Workers' Compensation Workers' Compensation Appeals Board Utilization Review Request for Authorization Service

Effective Jan. 1, 2022, the Workers' Compensation Appeals Board (WCAB) amended its Rules of Practice and Procedure to permit electronic service, including via email. The Labor Code, however, previously recognized electronic service of a request for authorization (RFA) for medical treatment. Specifically, LC 4610(i)(1) states: "The request for authorization and supporting documentation may be submitted electronically under rules adopted by the administrative director." To avoid complications and unnecessary delays in the utilization review (UR) process, the Labor Code and administrative regulations also specify to whom and how RFAs must be served. LC 4610(g)(2)(A) requires a requesting physician to send an RFA "to the claims administrator for the employer, insurer, or other entity according to the rules adopted by the administrative director." That language was adopted because physicians expressed difficulty in determining to whom an RFA should be sent. So the Labor Code clarifies that...

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