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Utilization Review

Utilization Review

In compliance with Labor Code Section 4610(g), the City of Burbank has partnered with Genex to administer the City’s Utilization Review (UR) program. Genex’s UR program is in compliance with the Medical Treatment Utilization Schedule (MTUS) as set forth in Title 8, California Code of Regulations section 9792.20 through 9792.27.23.

Q. What is Utilization Review?

A. Utilization Review is the process used by employers or claims administrators to determine if a proposed treatment requested for an injured worker is medically necessary.

Q. Is the City required to have a Utilization Review program?

A. Yes, Utilization Review is mandated by law.

Q. Is utilization review required in every case?

A. Yes, The California Supreme Court held that utilization review must be used for every medical treatment request in the California workers' compensation system. The court also held that approving requested treatment without physician review is part of utilization review (UR), and only reviewing physicians may decide to delay, deny or modify requested treatment.

Q. When does the utilization review process start?

A. The process starts at the onset of the claim.

Q. What is a Request For Authorization (RFA)?

A. An RFA is the form used by the doctor when treatment is requested. 

Q. Who is the City’s Utilization Review provider?

A. Genex

Q. How does Genex determine what should be certified or non-certified?

A. The Medical Treatment Utilization Schedule (MTUS) is a set of regulations found in title 8, California Code of Regulations section 9792.20 through 9792.27.23 that contain medical treatment guidelines and rules for determining what is reasonable and necessary medical care. 
(MTUS) details treatments scientifically proven to cure or relieve work-related injuries and illnesses. The MTUS lays out treatments that are effective for certain injuries, how often the treatment should be given, the extent of the treatment and other details. 

All doctors providing care to injured works must use the MTUS to determine if a treatment is medically necessary.

Q. What if the treatment my doctor recommends isn’t in the MTUS?

A. Your doctor needs to use other scientifically-based medical treatment guidelines generally accepted by the national medical community to support the recommended treatment. The MTUS provides guidance on what doctors should do to choose appropriate guidelines if the treatment is not in the MTUS.

Q. What if I disagree with the decision made by Utilization Review?

A. As of July 1, 2013, medical treatment disputes for all dates of injury will be resolved by physicians through the process of independent medical review (IMR). If UR denies or modifies a treating physician's request for medical treatment because the treatment is not medically necessary, you can ask for a review of that decision through IMR.

Along with the written determination letter that denied or modified your requested treatment, you will receive an unsigned but completed IMR form and addressed envelope. If you disagree with the decision, you must sign and send this form in the envelope to start the IMR process.
Your doctor can also appeal the UR decision by following the process outlined in the UR decision.

Q. What are the different types of Utilization Review?

A. The types are:

  • Prospective - any UR conducted prior to the delivery of the requested medical services.
  • Concurrent - submitted for treatment during an inpatient (hospital) stay.
  • Retrospective - after medical services have been provided and for which authorization has not already been given. 
  • Expedited - when the injured worker faces an imminent and serious threat to his or her health, including, but not limited to, the potential loss of life, limb or other major bodily function.

Q. Does Utilization Review have timeframes?

A. The timeframes are:

  • Prospective - Utilization review has 5 business days from the date the RFA is received. To issue a decision. If additional information is requested. Utilization Review has 14 business days to issue a decision.  
  • Concurrent – Utilization Review has 24 hours to issue a decision.
  • Retrospective - Utilization Review has 30 days to issue a decision.
  • Expedited - Utilization Review has 72 hours to issue a decision.

Q. Is there a cost saving to the City for Utilization Review?

A. No, there is no cost savings to the City. The City is charged a flat rate for the review regardless of the decision that is issued.

Q. I have a future medical award, does Utilization Review apply?

A. Yes. The law requiring UR went into effect Jan. 1, 2004. It applies to all medical treatment being given, even if you received your award before Jan. 1, 2004.