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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. 

  1. 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.
  2. 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 three days, a determination letter will be sent indicating approval or denial of payment for the service requested. Labor Commission rules allow for a five-day response time. At WCF Insurance, we strive to complete all Level I reviews within 72 hours. 
  3. 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 five 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 three to five days.
  4. 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. 
  5. For more information please refer to Labor Commission Rule 612-2-26. 
  6. 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. 


Contact Information:
Debra Mayo, RN, BS, CPUR, CCM                         
Manager, Utilization Review                                    


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Insurance coverage in all states other than Utah is provided by WCF National Insurance Company, formerly known as Advantage Workers Compensation Insurance Company, a wholly owned subsidiary of WCF Mutual Insurance Company. WCF National Insurance Company is domiciled in Utah; NAIC No. 40517. Administrative office: P.O. Box 571918, Salt Lake City, UT 84157-1918.
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