Workers' comp
Utilization review (UR)
The claims administrator's review of a treating doctor's request for authorization, approving, modifying or denying treatment under the medical guidelines.
What utilization review is
Every California workers' comp claims administrator must run a utilization review program. When the treating physician sends a request for authorization, UR applies the DWC's medical treatment utilization schedule (MTUS) to decide whether the treatment is medically necessary (Labor Code section 4610). Only a licensed physician competent in the clinical issue may modify or deny a request; non-physician staff can approve.
The rule and its timeframes
Prospective and concurrent decisions must be made within five normal business days of receiving the request and the information reasonably needed, and never more than 14 days from the doctor's recommendation. When the employee faces an imminent and serious threat to health, the decision is due within 72 hours. Decisions go to the requesting physician within 24 hours, then in writing to the parties (Labor Code section 4610). A UR decision that denies or modifies treatment on medical-necessity grounds is challenged through independent medical review, not at the WCAB.
Why it matters to an applicant firm
UR denials start the IMR clock: 30 days from service, or 10 days for formulary drugs. The dates UR received the request and issued its decision belong in the file too, since timeliness can itself be disputed. Applicant firms keep a log of each request for authorization, the date UR received it, the decision date and service date, and the IMR deadline that follows. The IMR and UR deadlines guide covers the sequence.
Sources
General information about California and federal rules, not legal advice. Rules change and every case turns on its facts: check the statute and your own analysis before relying on a date or a figure.