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Understanding California Workers’ Compensation Utilization Review

By Kenton Koszdin Law Office on August 19, 2013 | In Workers Compensation Claims

The utilization review (UR) process determines whether a requested medical treatment for a California worker injured on the job is medically necessary. Medically necessary treatments are typically covered by workers’ compensation, so it is crucial for workers who rely on the coverage of workers’ comp to be able to prove that their treatment is necessary.

California law requires employers or workers’ compensation claims administrators to have a UR program and to use it to decide whether or not to approve medical treatment recommended by a physician after a workplace injury or illness. Employers and claims administrators must use the UR process to reject a recommended treatment; they may not simply object to the medical report and use the AME/QME process instead of going through UR.

The UR process begins when a treating physician submits a request for authorization (RFA) for an injured worker. The review process can be carried out before, during, or after treatment. If the condition poses an imminent threat to the injured worker’s life or health, the review may be “expedited.” When a treatment is approved via UR, it must be paid for, even if the claims administrator or employer later determines the approval was made in error. This requirement allows physicians and injured workers to rely on the approval to start or continue treatment.

If you’ve been injured in a workplace accident or suffered a work-related illness, don’t wait. Contact the experienced southern California workers’ compensation attorneys at the Kenton Koszdin Law Office; your initial consultation with our office is free and confidential. Call us today at (800) 438-7734.

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