When you get benefits through workers’ compensation for medical treatment for a work-related injury or illness, it does not give you a blank check to get any medical treatment you want. You have to follow the rules and guidelines set by the workers’ compensation system and the law in California. This means every treatment or medical procedure you undergo requires approval through a utilization review.
The Division of Workers’ Compensation explains a utilization review is how an employer or claims administrator determines if a medical treatment is necessary for your injury or illness in order to approve the claim. The law requires this process with the determinations coming from state set treatment guidelines. All treatments in the guidelines are scientifically proven and include how effective they are and the duration, details and number of treatments you should receive.
Every medical treatment that you need will go through a UR. It is part of the legal requirement. This includes future treatments you get as part of your award. Do note that only a doctor can deny your treatment. A claims administrator can approve it, but not deny it. The guidelines are available to the public, so you can review them.
The UR process does not have to hold up needed treatment. Your doctor may be able to have it expedited. This will return a determination within 72 hours.
Getting a UR is nothing abnormal. It is part of the process. So, do not worry if you hear anything about this review process. This information is for education and is not legal advice.
