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Timeframes for Utilization Review to Approve or Deny Your Treatment

Posted by attorney Eric Overholt

THIS GUIDE IS NOT INTENDED TO BE USED AS LEGAL ADVICE AND SHOULD NOT BE USED IN PLACE OF AN EXPERIENCED ATTORNEY. ALSO, LAWS FREQUENTLY CHANGE. THIS GUIDE WAS WRITTEN IN MAY OF 2011 AND CANNOT POSSIBLY CONTEMPLATE FUTURE CHANGES IN THE LAW. IF YOU FIND YOURSELF USING THIS GUIDE, THEN PLEASE CONTACT AN ATTORNEY FOR LEGAL ADVICE. NO ATTORNEY-CLIENT RELATIONSHIP IS CREATED WITH MR. OVERHOLT OR HIS FIRM THROUGH THE VIEWING OR USE OF THIS GUIDE.

UR decisions must be made in a timely fashion that is appropriate for the nature of the employee's condition, not to exceed 5 working days from the receipt of the information reasonably necessary to make the determination, but in no event more than 14 days from the date of the medical treatment recommendation by the physician. LC 4610(g)(1).

However, if the treatment is required because of some threat to life, limb or some body function, then the time is 72 hours or shorter. See LC 4610(g)(2).

If the review of treatment is retrospective, then the timeframe is 30 days. See LC 4610(g)(1).

No person other than a licensed physician who is competent to evaluate the specific clinical issues involved in the medical treatment services, and where these services are within the scope of the physician's practice, requested by the physician may modify, delay, or deny requests for authorization of medical treatment for reasons of medical necessity to cure and relieve. See LC 4610(e), LC 4616(f).

Additional resources provided by the author

http://www.hrollp.com
http://www.dir.ca.gov/DWC/

Also see California Applicants' Attorney Association

For Information for Injured Workers' from the California Information and Assistance Unit, you can call 1-800-736-7401.

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