California Regulations 9792.6 153

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§ Utilization Review Standards

EDITOR'S NOTE: This section was technically repealed effective 1/1/04 by 2003 ch. 639 (SB 228) section 49, however the publisher has not yet received a Code of California Regulations register confirming this change - we have elected to continue the publication of this section pending said register.

(a) As used in this section: (1) 'Insurer' means a workers' compensation insurer, or an employer securing its liability under subdivision (b) or (c) of Section 3700 of the Labor Code. (2) 'Medical services' means those goods and services provided pursuant to Article 2 (commencing with Section 4600) of Chapter 2 of Part 2 of Division 4 of the Labor Code. (3) 'Health care provider' means a provider of medical services, including an individual provider, a health care service plan, a health care organization, or a preferred provider organization. (4) 'Request for authorization' means any written request for assurance that appropriate reimbursement will be made for a specific course of proposed medical treatment set forth in Form DLSR 5021, Section 14006, or in the format required for Primary Treating Physician Progress Reports in subdivision (f) of Section 9785. A verbal request for authorization or a written confirmation of a verbal authorization not a 'request for authorization' for purposes of this article. (5) 'Utilization review' is a system used to manage costs and improve patient care and decision making through case by case assessments of the frequency, duration, level and appropriateness of medical care and services to determine whether medical treatment is or was reasonably required to cure or relieve the effects of the injury. Utilization review includes, but is not limited to, the review of requests for authorization, and the review of bills for medical services for the purpose of determining whether medical services provided were reasonably required to cure or relieve the injury, by either an insurer or a third party acting on an insurer's behalf. Utilization review does not include bill review for the purpose of determining whether the medical services rendered were accurately billed, and does not include any system, program, or activity in connection with making decisions concerning whether a person has sustained an injury which is compensable under Division 4 (commencing with section 3200) of the Labor Code. (6) 'Written' includes an electronic facsimile or electronic mail, as well as communications in paper form.

(b) No later than July 1, 1996, any insurer which implements or maintains a system of utilization review shall maintain, and make available to the administrative director upon request, a written summary of the insurer's utilization review system, including: (1) A description of the process whereby requests for authorization are reviewed and decisions on such requests are made, including a concise description of how the requirements in subdivision (c) are met by the process. (2) A description of the specific criteria utilized in the review and throughout the decision-making process, including treatment protocols or standards used in the process. It shall include a description of the personnel and other sources used in the development and review of the criteria, and methods for up-dating the criteria. (3) A description of the qualifications of the personnel involved in implementing the utilization review system and the manner in which these personnel are involved in the review process.

(c) Any utilization review system shall comply with the following minimum standards: (1) Upon receipt of a written request for authorization, an insurer shall issue a authorization, denial, or notice of delay of decision to the health care provider, which shall be transmitted or placed in the U.S. mail no later than seven working days after the insurer's receipt of the request and any necessary supporting documentation. The authorization, denial, or notice of delay shall include some means of identification of the request, and shall include the name phone number of a responsible contact person. A notice of delay shall state what additional information is required to make a decision and when a decision regarding the request is expected to be made. (2) An insurer may use a non-physician reviewer to initially apply medically-based criteria to requests for authorization or to bills for medical services, but no request for authorization shall be denied, and no request for payment shall be denied or reduced on the basis that the services provided were not reasonably required to cure or relieve the injury, except by a physician with an unrestricted license by his or her licensing board who has education, training, expertise, and experience that is pertinent for evaluating the specific clinical issues or services under review. (3) Only medically-based criteria shall be used in the utilization review and decision-making process. The criteria applied in a particular case shall be made available to the affected health care provider and injured employee upon his or her written request. The criteria shall: (i) be based on professionally-recognized standards; (ii) be developed using sound clinical principles and processes; (iii) be developed by physicians, with involvement of actively practicing health care providers, and be peer-reviewed; (iv) be evaluated at least annually and updated if necessary; (v) be signed and dated by the physicians responsible for development. (4) If an insurer denies a request for authorization, or denies or reduces a bill for medical services on the basis that the services were not reasonably necessary to cure or relieve the effects of the injury, and the health care provider has not agreed to the denial or reduction, a written explanation of the basis of the denial or reduction must be submitted to the health care provider which includes: (i) the name of the reviewer; (ii) the telephone number of the reviewer, and hours of availability; (iii) the medical criteria upon which the denial is based. Authorization may not be denied on the basis of lack of information without documentation of a bona fide attempt to obtain the necessary information.

(d) Each insurer which implements or maintains a system meeting the requirements of this section shall advise the administrative director, as soon as practicable, of the date the system will be operational.

(e) If the administrative director finds that an insurer has implemented or maintained a utilization review system on or after July 1, 1996 which does not comply with this section, the administrative director shall notify the insurer in writing of such finding and provide the insurer with a reasonable period of time, not to exceed 90 days, to correct the noted deficiency. If the administrative director finds that revised system still does not comply with this section, he or she may take such action authorized under Labor Code section 129.5 as deemed appropriate under the circumstances.