Utilization Review (U/R)
The Utilization Review Program is a vital tool in preventing the inappropriate, excessive or medically unnecessary treatment of an injured worker.
Physicians who initially receive patients from CompCHOICE are authorized to evaluate injured employees through physical examination to determine a working diagnosis. The physician is also authorized to begin treatment when appropriate and necessary. The physician is expected to submit to CompCHOICE a detailed treatment plan within 48 hours, in order to ensure physician and patient compliance to prescribed treatment.
When a change in the patient’s medical condition requires a variance from the original treatment plan, the physician should document the change by submitting a new, detailed treatment plan to CompCHOICE. These processes allow physicians to make critical, timely decisions regarding medical care and enable the CompCHOICE Case Manager to access detailed information regarding prescribed treatment in advance of prolonged care.
Throughout the course of treatment, the treating physician is required to document and justify to the CompCHOICE Medical Director the need for continued care and further implementation of the treatment plan. A physician’s failure to justify the need for additional care will result in the Case Manager proactively securing a second opinion evaluation from another qualified provider.
No pre-authorization is required to provide emergency (life- or limb-threatening) medical treatment.
Pre-authorization is required for the following:
- Hospital admission
- Surgery (inpatient and outpatient procedures)
- Diagnostic tests (i.e., MRI, CT, nerve conduction studies, bone scan)
- Ancillary services (physical therapy, rehabilitation, etc.)
The Official Disability Guidelines (ODG) are used as a resource and guideline to ensure treatment recommendations and authorizations are consistent with evidence-based medical reviews.
U/R services are provided on a stand-alone basis or as a component of the CompCHOICE Certified Workplace Medical Plan (CWMP).
To facilitate U/R processes, CompCHOICE provides a local and nationwide toll-free telephone number for the benefit of employers, employees and providers: