Utilization Review Process
Information Applies to Utah Claims
Utilization Review (UR) is the process whereby qualified nurses and physicians review requests for specific services and procedures and determine medically necessary and appropriate treatment related to an industrial injury. The WCF Insurance UR process complies with the Utah State Labor Commission Rules and Regulations.
- Level I Review: The provider is required to obtain preauthorization from WCF Insurance prior to providing services and procedures to an injured worker. The provider submits a request in writing to the claims department indicating claimant name, date of birth, date of injury and claim number (if known) along with a request for services and supporting medical documentation.
- Based on our claims criteria, the adjuster immediately refers certain requests to our UR department where it is reviewed by a nurse. A nurse follows ODG and ACOEM guidelines and WCF Insurance medical policies to determine if the requested procedure is medically necessary or appropriate. Some procedures such as spinal fusion surgery are reviewed by physicians only. Within 3 days, a determination letter will be sent indicating approval or denial of payment for the service requested. Labor Commission rules allow for a 5 day response time. At WCF Insurance, we strive to complete all Level I Reviews within 72 hours.
- Level II Review: An appeal process is in place for a provider who wishes to appeal the UR Level 1 decision. The Labor Commission rules allow an additional 5 days from the date of receipt of the request for an appeal. The provider must submit a letter of explanation with new supporting documentation for the medical service or procedure. All Level II Reviews are completed by a physician reviewer and the determination letter will be sent within 3-5 days.
- A provider may request a peer to peer consult with the WCF Insurance Medical Director. In most instances calls will be returned within 48 hours.
- For more information please refer to Labor Commission Rule 612-2-26 Utilization Review Standards.
- Restorative therapy also requires pre-authorization. This includes medical, osteopathic, chiropractic and occupational and physical therapy. Providers must submit the RSA Form 221 to the claims department. Please refer to Labor Commission Rule R612-2-2-3.
Debra Mayo, RN, BS, CPUR, CCM
Manager, Utilization Review