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California Workers' Compensation Guide

Understanding Utilization Review (UR)

What is Utilization Review?

Under California Labor Code Section 4610, Utilization Review (UR) is the official process used by employers and claims administrators to review medical treatment recommended by your doctor. UR ensures that requested medical care is medically necessary and meets state-approved guidelines.

Step 1: Request for Authorization (RFA)

The UR process is triggered when your primary treating physician (PTP) submits a formal Request for Authorization (RFA):

  • Evidence-Based Standards: Treatment recommendations must align with the California Medical Treatment Utilization Schedule (MTUS) guidelines.
  • Who Can Approve: Non-physician claims examiners can approve recommended care.
  • Who Can Deny or Modify: Only a licensed physician with appropriate clinical expertise can modify, delay, or deny a treatment request.

Step 2: Review Types & Decision Timelines

The state enforces strict time limits for claims administrators to issue UR decisions:

Review Type Description Mandatory Timeframe
Prospective Review Treatment requested before care is provided. 5 business days from receipt of RFA.
Concurrent Review Treatment requested during an ongoing hospital stay or extended care. 5 business days (or 24 hours for acute inpatient care).
Expedited Review Urgent requests where standard review poses a serious health threat. 72 hours max from receipt of medical documentation.
Retrospective Review Evaluation of medical care after treatment was already rendered. 30 days from receipt of medical bills/records.

Step 3: UR Outcomes & Written Notifications

Once a determination is made, the claims administrator must notify all parties:

  1. Approval: Oral or written notification is sent within 24 hours of decision, followed by formal written confirmation within 2 business days.
  2. Modification or Denial: A detailed written explanation citing specific MTUS guideline failures must be sent to you, your doctor, and your attorney within 2 business days.
  3. Delays (Information Needed): If additional medical records or tests are needed, the insurer can extend the review period up to 14 days (or 30 days for additional exams).

Step 4: Challenging a UR Decision

If your treatment request is modified or denied by UR, you have immediate rights to appeal:

  • Independent Medical Review (IMR): A UR denial cannot be overturned by a WCAB judge directly; it must be appealed through the Independent Medical Review (IMR) process within 30 days.
  • IMR Application Form: The insurer is required to enclose a blank Application for Independent Medical Review along with their written UR denial notice.

Untimely Decisions: If a claims administrator fails to issue a UR decision within the legal timeframes, the decision becomes invalid, and your medical request may be eligible for immediate authorization or judicial relief through the WCAB.