San Francisco, CA – A second 15-day notice of modification to the proposed utilization review (UR) and independent medical review (IMR) regulations has been distributed to interested parties and posted to the DWC website. Members of the public are invited to present written comments regarding the proposed modifications to dwcrules@dir.ca.gov until 5 p.m. on December 21, 2013.
The proposed modifications include:
- Revisions to the Request for Authorization form (DWC Form RFA) and the Application for Independent Medical Review (DWC Form IMR).
- Section 9792.9.1(c)(2): A non-conforming request for authorization (i.e., an incomplete Form RFA or request that does not use the form) must be returned to the requesting physician within 5 business days or else be considered as complete and subject to all applicable timeframes and requirements. A non-conforming request that does not use the Form RFA must have: (1) “Request for Authorization” clearly written at the top of the first page of document; (2) all requested medical services, goods, or items listed on the first page; and (3) documentation substantiating the medical necessity for the requested treatment.
- Section 9792.9.1(f)(2): A claims administrator is allowed up to five (5) business days following receipt of the request for authorization to request additional information, an additional test, or consultation by an expert reviewer.
- Section 9792.10.1(d)(2): An internal utilization review appeal must be completed within thirty (30) days after receipt of the appeal.
- Section 9792.10.3(f): The Administrative Director retains the right to determine the eligibility of a request for independent medical review until an appeal of the final independent medical review determination has been filed with the WCAB or the time for such an appeal has expired.
- Section 9792.10.6(b)(2): If a claims administrator fails to submit medical records, a medical reviewer may, if possible, issue an IMR determination based on a summary of medical records listed in the utilization review determination and any documents submitted by the employee or requesting physician.
- Section 9792.10.6(g): Clarifies the 30-day time frame for issuing a final IMR determination in cases where IMR requests are consolidated or where a utilization review decision is modified following an internal appeal.
- Section 9792.12(c): Administrative penalties are clarified for the failure of a claims administrator to provide an IMR application with an adverse utilization review decision, and for the failure to complete all applicable fields of the form.
The notice, text of the regulations, and forms can be found on the proposed regulations page.