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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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Expedited Review of Requests for Treatment Revisited

Posted by:  Sure S. Log
Topics: Utilization Review Medical Treatment expedited review LC 4610 UR CCR 9792.9.1 UR determination UR decision imminent and serious threat medical necessity

Labor Code 4610(i)(1) normally requires a utilization review (UR) determination to be made within "five normal business days from the receipt of a request for authorization for medical treatment and supporting information reasonably necessary to make the determination, but in no event more than 14 days from the date of the medical treatment recommendation by the physician." But LC 4610(i)(3) requires an expedited review when the employee faces an "imminent and serious threat to his or her health, ... or the normal timeframe for the decision-making process ... would be detrimental to the employee’s life or health or could jeopardize the employee’s ability to regain maximum function." In those situations, the UR decision must be made in a timely fashion "not to exceed 72 hours after receipt of the information reasonably necessary to make the determination."

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