7 CCR 1101-3-17-10 - Medical Utilization Review
10-1 REQUESTS
FOR UTILIZATION REVIEW
(A) A party shall
request a utilization review by filing the Request for Utilization Form
(request form) with the Division Utilization Review Coordinator. The request
form must be the one prescribed by the Division, but a duplicated or reproduced
request form may be used as long as it is an exact version of the original in
both appearance and content.
(B)
The provider under review shall remain as an authorized provider for the
associated claimant during the medical utilization review process. The provider
shall continue to submit bills for services rendered to the associated claimant
during the review period and the insurance carrier shall continue to pay the
provider's bills as provided in these rules of procedure.
(C) As provided in section 10-2, below, an
information package and medical records package shall be filed with the request
form.
10-2 FILING A
REQUEST FOR UTILIZATION REVIEW
(A) One copy of
an information package shall be filed and shall contain the following items:
(1) completed and signed Division prescribed
request form.
(2) copies of all
admissions filed or orders entered in the case.
(3) a list containing the full names and
medical degrees of all providers, including the provider under review, other
treating providers, and individuals who are considered as referrals or who
performed consultations, independent medical examinations and/or second
opinions, and
(4) The minimum
filing fee as provided in section 10-2(E)
(B) In addition, seven (7) copies of a
medical records package shall be filed in accordance with the instructions on
the prescribed request form, Each copy shall be two-hole punched at the top
center of each page and securely fastened. (Notebooks and plastic type covers
and binders shall not be used). A blank sheet of paper shall be placed and
bound to the front and back of each copy of the submitted material and if tabs
are used to divide sections, they shall be positioned to the right side of the
document and each copy shall contain the following items:
(1) A table of contents;
(2) A case report, which shall be prepared,
signed and dated by a licensed medical professional. This report shall be dated
within thirty (30) days prior to the date of filing with the Division pursuant
to §
8-43-501(2)(b).
The case report shall be limited to the following:
(a) name, discipline of care and specialty of
the provider under review,
(b)
claimant's standard demographic information (age, sex, marital status,
etc.),
(c) claimant's employer and
occupation/job title, date(s) of claimant's work-related injury/exposure(s),
and,
(d) Date of initial treatment,
a brief chronological history of treatment to the present date, and any
significant contributing factors which may have had a direct effect on the
length of treatment; (e.g., diabetes).
(e) A brief statement from the medical
professional after review of the medical records in support of utilization
review.
(3) The
following sections:
Section 1 - a copy of the Employer's First Report of Injury and/or the Worker's Claim for Compensation form.
Section 2 - all reports, notes, etc., from the provider under review as submitted to the requesting party.
Section 3 - all reports, notes, etc., of the other treating providers as submitted to the requesting party.
Section 4 - all reports resulting from referrals, consultations, independent medical examinations and second opinions as submitted to the requesting party.
Section 5 - all diagnostic test results as submitted to the requesting party.
Section 6 - all medical management reports as submitted to the requesting party.
Section 7 - all hospital/clinic records related to the injury as submitted to the requesting party
(C) The medical records package shall not
contain billing statements, adjustor notes, vocational rehabilitation records,
surveillance tapes or reports, admissions, denials or comments directed to the
utilization review committee.
(D)
All material contained in the medical records package shall be presented in
identified sections, each section's contents presented in chronological
order.
(E) A minimum filing fee of
$ 1,250.00 shall be paid at the time of filing by the requesting party. The
Division will notify the requesting party of additional costs incurred, such as
payment to panelists not covered by the filing fee, which require a
supplemental fee. Payment of any such supplemental fee will be required for
completion of the utilization review and prior to the issuance of the
Director's order.
10-3
OFFICIAL NOTIFICATION OF UTILIZATION REVIEW
(A) The Division will notify in writing the
provider under review of the review request, and provide a copy of the written
notification to each party to the case.
(B) Along with the written notification, the
provider under review, as well as each party to the case, will receive one copy
of the medical records package as filed by the requesting party.
(C) Within seven (7) days of receiving the
written notification, the provider under review may submit a concise written
statement no longer than two (2) pages in length, limited to whether the
treatment provided was reasonably necessary or reasonably appropriate. The
provider shall supply seven (7) copies of the statement to the division. A
timely and properly submitted written response will be added to the review
packets and forwarded to all parties by the division.
(D) Any motions or requests regarding the
utilization review must be submitted, in writing, to the Medical Utilization
Review Coordinator. Until such time as the Director issues a final order, the
medical utilization review is an internal process at the Division, under the
jurisdiction of the Director.
10-4 ADDING MEDICAL RECORDS TO THE
UTILIZATION REVIEW FILE
(A) The Division will
not accept additional medical records filed by any individual who has not been
identified as a party to the case.
(B) The Division will incorporate all
properly and timely filed additional medical records into the review file.
Additional medical records that are not filed timely and properly will not be
included in the review file.
(C)
Parties filing additional medical records should not duplicate records already
submitted for review. Seven copies of any additional medical records must be
provided.
(D) The provider under
review and each party to the case shall have one opportunity to submit
additional medical records. Medical records must be received or postmarked
within thirty (30) days from the mailing of the review notification. This
thirty (30) day period can be extended upon a written request which sets forth
good cause.
(E) Any additional
medical records shall be presented as follows:
(1) The first item in each copy shall be a
dated and signed transmittal letter which contains the following information:
(a) The UR# and claimant's name,
(b) Identification of the submitting party
name and relationship to the case,
(c) a certification stating the seven (7)
copies of additional medical records contain the same documents, and
(d) an index of the additional attached
medical records material.
(2) The presentation of any additional
medical records shall be in an identical manner to those as provided in section
10-2(B), above.
(F) The
Division will send the provider under review and each party to the case a copy
of all properly filed additional medical records.
10-5 Selection of Utilization Review
Committee Members
(A) The Director, with input
from the Medical Director, shall appoint appropriate peer professionals to
serve on the utilization review committees for three years.
(B) A committee member may be suspended from
participation if the member has been the subject of a utilization review which
resulted in an order for change of provider, retroactive denial of payment of
medical bills and/or revocation of accreditation.
(C) Committee members shall be paid a fee of
$225 per hour for their time incurred in preparing and completing their reports
and recommendations to the director. Services rendered by the committee members
on behalf of the Division shall be concluded upon acceptance by the Division of
their final reports and recommendations. Any party to a claim for benefits or
any party to a utilization review proceeding who requests the presence as a
witness of one or more committee members at a proceeding for any purpose, by
subpoena or otherwise, shall be responsible for payment to said committee
member(s) pursuant to the fee schedule set forth in these rules of
procedure.
(D) A provider may not
serve on a UR Committee unless his or her professional license or
certification, if applicable, is current, active and unrestricted.
(E) After the members of the utilization
review committee have been established, the provider and each party to the case
will receive written notice of the names of the committee members. Within ten
(10) days of receiving the written notification, any allegation that a
committee member has a conflict and should be removed from the committee must
be submitted in writing to the medical utilization review coordinator, setting
forth the basis for the alleged conflict. Any such allegations that are not
raised in a timely manner are deemed to have been waived and will not be
considered at any subsequent stage of the utilization review proceedings. A
conflict will be presumed to exist when the provider under review and a member
of the review committee have a relationship which involves a direct or
substantial financial interest. The following guidelines apply to any
allegations of conflict under this Rule:
(1)
Direct or substantial financial interest is a substantial interest which is a
business ownership interest, a creditor interest in an insolvent business,
employment or prospective employment for which negotiations have begun,
ownership interest in real or personal property, debtor interest or being an
officer or director in a business.
(2) The relationship will be reviewed as of
the time the utilization review is being conducted. Relationships in existence
before or after the review in and of themselves will have no bearing, unless a
direct or substantial financial interest is raised at the time of the
utilization review.
(3) Being
members of the same professional association or medical group, sharing office
space or having practiced together in the past are not the types of
relationships which will be considered a conflict, absent a direct or
substantial financial interest.
(4)
Any provider who has provided services to the claimant in the case for which
the utilization review has been requested, or who has any type of personal or
professional relationship with the claimant, will not be allowed to serve on
the utilization review committee.
(5) This rule is not intended as an
opportunity to conduct discovery. Depositions, interrogatories or any other
type of discovery will not be permitted in order to make determinations as to
whether a conflict exists.
(F) Members of UR Committees shall not review
any material other than what is provided by the Division, and shall not engage
in communication regarding the Utilization Review with any person other than
Division staff, except under the following circumstances: by approval of the
Director; by written agreement of the parties to the case, including the
provider under review; the provider under review and the parties to the case
are strictly prohibited from having any communication with the members of the
UR committee while the review is pending.
10-6 COMPOSITION OF UTILIZATION REVIEW
COMMITTEES
(A) The Division will strive to
compose utilization committees that reflect a balance of interests. Membership
of the committees may include the following:
(1) Joints/Musculoskeletal Committee - Two
practitioners licensed in the same discipline of care as the provider under
review and one occupational medicine practitioner (M.D. or D.O.) with a minimum
of 2 years experience in occupational medicine where 30% of practice time is in
occupational medicine cases or a minimum of 5 years of experience with a
minimum of 15% of practice time in occupational medicine cases;
(2) Dental Committee (Teeth only) - three
dentists;
(3) Psychiatry Committee
- One occupational medicine practitioner (M.D. or D.O.) and two psychiatrists;
and,
(4) Other - Committee shall be
determined by the Director to meet the specific circumstances of the
utilization review case.
10-7 RESPONSIBILITIES OF UTILIZATION REVIEW
COMMITTEE MEMBERS
(A) Each committee member
shall perform the review based on the materials provided, and work
independently while performing his/her review. The review shall be a paper
review only unless a specialist opinion is requested by a majority of the
committee members. The specialist's opinion may require a physical examination
of the claimant.
(B) When
performing a utilization review, the members of the medical utilization review
committee shall consider all applicable medical treatment guidelines under
these rules of procedure. The Division shall provide copies of the appropriate
guidelines to the committee upon request.
(C) The report of each member of the
utilization review committee should be limited to answers to the specific
questions submitted by the Division, along with a written narrative supporting
or explaining the answers for each of the questions.
10-8 CHANGE OF MEDICAL PROVIDER
(A) If the Director orders that a change of
provider be made, the claimant and insurer or self-insured employer shall
follow the procedures set forth in §
8-43-501(4) in
order to obtain a new provider. The parties shall notify the Division, on the
prescribed form, as to whether the parties have agreed upon a new provider or
whether the Director shall select the new provider as provided in §
8-43-501(4).
(B) If the claimant chooses to remain under
the care of the provider under review during the period of appeal resolution,
the payor shall be responsible for payment of medical bills to the provider
until an order on appeal is issued. If the insurance carrier, employer or
self-insured employer prevails on appeal, the claimant may be held liable by
the prevailing party for such medical costs paid during the appeal
period.
(C) A provider who wishes
to become a new treating provider candidate shall not be eligible unless his or
her professional license or certification, if applicable, is current, active
and unrestricted.
10-9
UTILIZATION REVIEW APPEALS
(A) The appealing
party shall complete the appeal form prescribed by the Division. The form shall
be filed with the Medical Utilization Review coordinator within the timeframes
set forth in the appeal procedures.
(B) Should the Director order both
retroactive denial of fees and change of provider, upon appeal the issues shall
be separated and transferred to the Office of Administrative Courts for a de
novo hearing on retroactive denial or a record review for change of
provider.
(C) Should the appealing
party be entitled to a de novo hearing, the hearing shall be scheduled
according to the instructions on the appeal form. The appealing party must file
an application for hearing with the Office of Administrative Courts and a copy
must be provided to the Medical Utilization Review Coordinator.
Notes
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