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What is a workers’ compensation utilization review?

On Behalf of | Aug 1, 2022 | Workers’ Compensation

Kentucky workers who are injured on the job will rely on workers’ compensation benefits to help them make ends meet and get the medical care they need. However, there are often challenges that come up as they are seeking benefits or after they have been approved. Many are unfamiliar with the terminology and requirements. A key part of the claim that should be considered is medical care, the utilization review and its process.

Utilization reviews and determining medical necessity

Since medical coverage can be extraordinarily expensive, insurers and employers will keep an eye on what care is being provided and scrutinize if it is necessary. In a utilization review, an insurer gauges the medical treatment to determine whether it is appropriate and required based on the injury.

When a claim is under utilization review, medical professionals look at the injury or condition to decide if the treatment is necessary. These reviewers are medical professionals. They will analyze the case and how the worker’s condition is generally treated. The initial decision will be released within two working days if it is for preauthorization. There are 10 working days if the treatment has already been provided. In some cases, the review is expedited and will be done in 24 hours.

When there is a problem during the initial review, the claim goes to a licensed physician. A denial can only be made by physicians. The notice must say why it is being denied and give the name and professional information of the reviewer. The worker has the right to appeal the denial. The worker can ask for reconsideration within 14 days of being notified that the claim was denied. A different reviewer will look at the case. There will be 10 days to make the determination.

If the reconsideration is denied, there is a third level of appeal where a specialist or sub-specialist can be asked to assess the case. This can only be done if a specialist played no role in the previous parts of the case. When the specialist denies the claim, this will be the final step in the process.

Professional help

When a worker is injured and needs workers’ compensation benefits, they will want the approval and to get the care and payments as quickly as possible. However, it can sometimes be a difficult process with obstacles along the way. If problems arise at any point related to the utilization review or any other aspect of workers’ comp, it is wise to have legal assistance to be protected.