Utilization Review is the evaluation, by an outside source, of the necessity, appropriateness, efficiency, and quality of medical care services provided to an injured employee.  It is required when:

• The medical necessity of a treatment recommended by an authorized treating medical provider is disputed by the insurance adjuster; and,
• In instances required by the workers’ compensation statutes or medical fee schedule (e.g., hospital admissions, physical or occupational therapy, chiropractic care, clinical psychological treatment).

UR provides for the review of selected outpatient and inpatient health care providers and pre-admission review of all hospital admissions, except for emergency services.

Recommended medical treatment(s) may be approved by the insurance adjuster, a registered nurse or an Advisory Medical Practitioner, which is an actively TN-licensed practitioner, who is board-certified and in the same or similar general specialty as the authorized treating physician.  An adjuster cannot deny a recommended treatment as not being medically necessary.  The recommended treatment can only be denied by an Advisory Medical Practitioner.

• The adjuster has three (3) business days after being notified of the recommended treatment to approve the treatment or send the recommendation to its utilization review agent.
• The utilization review agent has seven (7) business days to make a decision on the recommended treatment and notify all parties of the decision. If the utilization review agent does not possess all necessary information in order to render the utilization review determination, then they shall request additional information, in writing, from the authorized treating physician, who shall comply with the request within five business days of receipt of the written request. The number of business days is extended until the utilization review agent receives the necessary information or until the five (5) business day timeframe expires, whichever occurs first.
• The decision reached by the utilization review agent can only address medical necessity and not causation and/or compensability.  An approval of the treatment by the utilization review agent is final and not subject to appeal.
• If an authorized treating physician has sought to provide specific medical treatment, but the treatment has been denied by the employer through a utilization review process, injured workers should seek the assistance of this program.  Denials of recommended treatment must be accompanied by a utilization review report that gives the reasons for denial and contact information for the utilization review physician.  Denials must also be accompanied by an Utilization Review Appeal Form (Form C-35A) so the injured worker, their attorney and treating physician are informed of the proper procedure to request an appeal with the Division.
• After a denial, the injured worker, their attorney or treating physician has thirty (30) calendar days from receipt to appeal the utilization review decision to the Division at the address listed on the form.  After a complete medical record is received, the Division of Workers’ Compensation’s Medical Director, or his/her designee, will determine if he/she agrees with the insurance carrier’s utilization review denial.  If the Medical Director, or his/her designee, disagrees with the utilization review decision, an order for the treatment recommended by the authorized treating physician will be issued.

To view the Utilization Review Program Rules, click here.
To view the Utilization Review Appeal Fee Notice, click here.

For additional information about this topic, please call 615-532-4812 or 1-800-332-2667.

IMPORTANT NOTES:

• UR services must be provided or contracted for/by each insurer who provides workers’ compensation insurance in Tennessee as well as every self-insured employer.  The self-insured employer may choose to provide the services itself or through a third party administrator.
• The UR Agent conducting the review services for the employer must be registered with the Division of Workers’ Compensation and the Tennessee Department of Commerce and Insurance.
• A health care provider who is found to have rendered excessive or inappropriate services may be subjected to:
  • Forfeiture of the right to payment for the services rendered;
  • Payment of civil penalty of not less than $100.00 nor more than $1,000.00; or,
  • Temporary or permanent suspension of the right to provide medical care services for workers’ compensation claims if the healthcare provider has established a pattern of violations.
• An employer, insurer, third party administrator, or UR Agent who is found to have violated the UR rules may be subjected to a penalty of not less than $100 nor more than $1,000 per violation.  The Division may also institute a temporary or permanent suspension of the right to perform utilization review services for workers’ compensation claims, if the utilization review agent has established a pattern of violations.

Please note that the Tennessee Department of Labor is the author of this content and the original article can be found at http://www.tn.gov/labor-wfd/wcomp/providers_info.shtml#UTIL_REVIEW