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Utilization review (UR) is the process used by employers or claims administrators to review treatment to determine if it is medically necessary. All employers or their workers' compensation claims administrators are required by law to have a UR program. This program is used to decide whether or not to approve medical treatment recommended by a physician.
California has adopted a set of medical treatment guidelines, which lay out treatments scientifically proven to cure or relieve work-related injuries and illnesses. They also deal with how often the treatment is given and for how long, among other things. The DWC's final medical treatment guideline regulations, formally called the medical treatment utilization schedule (MTUS), became effective June 15, 2007. Among other provisions, the MTUS regulations incorporate the American College of Occupational and Environmental Medicine's Occupational Medicine Practice Guidelines (ACOEM Practice Guidelines) and acupuncture treatment guidelines. The rules also lay out the strength of evidence rating methodology by which specific medical treatments or diagnostic services are evaluated.
In its regulations, the DWC also created a medical evidence evaluation advisory committee, which advises the DWC medical director on potential revisions, updates and supplements that will keep California's treatment guidelines current.
The MTUS is presumed to be correct on the issue of extent and scope of medical treatment and diagnostic services it addresses. However, that presumption can be set aside by a preponderance of scientific medical evidence that shows a variance from the schedule is reasonably required to cure or relieve the injured worker from the effects of his or her injury. For all conditions or injuries not addressed by the MTUS, authorized treatment and diagnostic services must be in accordance with other scientific, evidence-based medical treatment guidelines that are nationally recognized by the medical community.
The UR process is governed by Labor Code section 4610 and regulations written by the CA Division of Workers' Compensation (DWC), which lay out timeframes and other rules for conducting UR. The rules, contained in Title 8, California Code of Regulations, sections 9792.6 et seq, also require UR plans to be filed with the DWC administrative director. Additionally, the DWC has promulgated regulations that provide for penalties to apply when claims administrators and UR companies don't follow UR rules. The UR penalty regulations, found in Title 8, California Code of Regulations, sections 9792.11 - 9792.15, provide an enforcement mechanism to ensure utilization reviews are conducted in compliance with UR regulations
UR rules
Final utilization review regulations
Final utilization review penalty regulations
UR forms, fact sheets and frequently asked questions (FAQs)
- Utilization review complaint form
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Note: If you want to save this form to your computer and email it to the DWC Medical Unit, you MUST use the Word version. The PDF version cannot be saved to your computer once filled.
- Utilization review fact sheet for injured workers
Respuestas a sus preguntas sobre la revisión de utilización
- Answers to frequently asked questions about utilization review (UR) for claims administrators.
Who has a UR program on file with DWC?
Submitted utilization review plans version version
A list of the groups that have sent actual UR plans to the DWC. The list does not contain the names of individual employers that might be covered by these plans.
UR news
| Jun. 18, 2008 | California Division of Workers’ Compensation posts results of utilization review investigations on its Web site 
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| Jun. 27, 2007 | Division of Workers' Compensation advises claims administrators to continue to pre-approve certain requests for treatment Penalty regulations not intended to drive all requests for treatment to a formal utilization review process |
| Jun. 15, 2007 | Medical treatment guideline regulations approved |
| Jun. 7, 2007 | Utilization review enforcement regulations approved |
| May 8, 2007 | The California Division of Workers' Compensation files final medical treatment guideline regulations with the Office of Administrative Law |
| Apr. 26, 2007 | The California Division of Workers' Compensation files final regulations for utilization review enforcement with the Office of Administrative Law |
| Mar. 29, 2007 | Division of Workers' Compensation issues second 15-day notice of revisions to proposed medical treatment guideline regulations |
| Mar. 21, 2007 | Division of Workers' Compensation issues fourth 15-day notice of revisions to proposed utilization review enforcement regulations |
| Mar. 9, 2007 | Division of Workers' Compensation issues third 15-day notice of revisions to proposed utilization review enforcement regulations |
| Mar. 2, 2007 | Division of Workers' Compensation medical guideline advisory committee will begin work March 19 to supplement treatment guidelines |
| Feb. 7, 2007 | Division of Workers' Compensation issues 15-day notice of revisions to proposed utilization review enforcement regulations |
More news archives can be found on the DWC newsline page at www.dir.ca.gov/dwc/dwc_newsline2007.html.
Access to the ACOEM guidelines
Copies of the ACOEM guidelines are available for review at local DWC offices. The ACOEM guidelines are also available at many law, university and public libraries.
For purposes of compliance with the California Code of Regulations, Title 8, division one, chapter 4.5, subchapter one, article 5.5.1, utilization review standards, a claims administrator may make copies of incidental portions of original editions of Occupational Medicine Practice Guidelines, Second Edition, as necessary in connection with a decision to modify, delay or deny services in a specific case under review. Such copies may not be published on the Internet or in any other media. All rights in the Guidelines are reserved by ACOEM. If you have any questions, please contact ACOEM, 25 Northwest Point Boulevard, Suite 700, Elk Grove Village, IL, 60007 (http://www.acoem.org, 847-818-1800).
October 2008