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UR Medication - Printable Version

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UR Medication - kibby - 10-28-2018

What is the official process to start Utilization Review for Medication. Does UR happen as soon as I go to the pharmacy with my WC pharmacy card, they call the number and they deny it and it officially goes into the system for review or do I need to contact my attorney every time they deny. 
Side note: Anyone know how to find a list with doctors on lien?


RE: UR Medication - 1171 - 10-28-2018

Are you aware of the rules using the new drug formulary that lists which drugs the state will allow?
The formulary is here
https://www.dir.ca.gov/dwc/MTUS/MTUS-Formulary.html
The rules are here
https://www.dir.ca.gov/dwc/DWCPropRegs/MTUS-Formulary/Final-Regulations/Text-Of-Regulations.pdf

Your atty should have a copy of every lien/ provider filed on your claim.
The board will also have a copy of the filed liens in your litigation folder.

Your physician can get pre approval.


RE: UR Medication - kibby - 10-29-2018

(10-28-2018, 01:56 PM)1171 Wrote: Are you aware of the rules using the new drug formulary that lists which drugs the state will allow?
The formulary is here
https://www.dir.ca.gov/dwc/MTUS/MTUS-Formulary.html
The rules are here
https://www.dir.ca.gov/dwc/DWCPropRegs/MTUS-Formulary/Final-Regulations/Text-Of-Regulations.pdf

Your atty should have a copy of every lien/ provider filed on your claim.
The board will also have a copy of the filed liens in your litigation folder.

Your physician can get pre approval.
Doctor refuses to write for any other medication besides this one. I was just curious how a UR happens for a med. Is it triggered automatically when I try and fill it? 
Sorry, I should have been more clear. I am trying to find a doctor that will accept a lien. I want to get treated elsewhere seeing as my doctor now will not refer me to an orthopedic surgeon and I have spinal stenosis. I was previously being treated by an orthopedic surgeon in California and moved. 
I have been seeing this doctor for a year and everything gets denied each month I go to him. Refuses to change treatment plan. His words are" If they don't like it, tough. This is my treatment plan and I will not deviate" and as you know UR's are binding for a year. He won't for example even change T3 facet block to a T4 facet block on paper(even though I need facet blocks in most my T spine). I said please refer me to an orthopedic surgeon like I was seeing in California and he goes "Why do you want to see an orthopedic surgeon, they won't be able to do anything for you" so I am stuck. Thanks for the med info, was more looking for how a UR is triggered. Do I have to call my attorney each time they deny the script at the pharmacy desk or is it done automatically


RE: UR Medication - 1171 - 10-29-2018

California UR is triggered either by prospective request or retrospective notice.

From the DWC links:
https://www.dir.ca.gov/dwc/MTUS/MTUS-Text-of-Regulations.pdf

There is no list; whether a physician will treat under lien is generally on a case by case decision. Maybe comp attys in your current state know who might be likely to treat a litigated out of state comp claim.

As the costs of treatment has escalated, out of state care for comp is disappearing fast.


RE: UR Medication - kibby - 10-29-2018

(10-29-2018, 12:50 PM)1171 Wrote: California UR is triggered either by prospective request or retrospective notice.

From the DWC links:
https://www.dir.ca.gov/dwc/MTUS/MTUS-Text-of-Regulations.pdf

There is no list; whether a physician will treat under lien is generally on a case by case decision. Maybe comp attys in your current state know who might be likely to treat a litigated out of state comp claim.

As the costs of treatment has escalated, out of state care for comp is disappearing fast.
Yeah no kidding. It costs them 800 dollars a month just in transportation alone to send me to this doctor. After doctor fees, hotel etc etc it costs them 1600 dollars. Throw in the UR that's 2k Big Grin


RE: UR Medication - California_Help - 10-29-2018

(10-29-2018, 01:15 PM)kibby Wrote:
(10-29-2018, 12:50 PM)1171 Wrote: California UR is triggered either by prospective request or retrospective notice.

From the DWC links:
https://www.dir.ca.gov/dwc/MTUS/MTUS-Text-of-Regulations.pdf

There is no list; whether a physician will treat under lien is generally on a case by case decision. Maybe comp attys in your current state know who might be likely to treat a litigated out of state comp claim.

As the costs of treatment has escalated, out of state care for comp is disappearing fast.
Yeah no kidding. It costs them 800 dollars a month just in transportation alone to send me to this doctor. After doctor fees, hotel etc etc it costs them 1600 dollars. Throw in the UR that's 2k Big Grin

The links 1171 provided explains UR well.

There could be many reasons why your medications are being denied. When you write denied do you mean the pharmacy does just not get approval to refill it or do you get a UR denial in the mail? Sometimes the pharmacy needs to run it a few times, especially if it is CVS.

If your doctor is not requesting your medication on an RFA form the adjuster can ignore the request.

If your claim is denied it will most likely be filled.

There are reasons to get a request again before the 12 month period. A change of condition or material facts known. This could be an increase in pain for example or new facts known like you got an MRI that shows material facts not previously known OR even if the MRI you had previously but the information was not previously provided to UR. Your doctor would need to check off the box on the RFA that states change of condition or material facts known. He should also explain the change.

If your doctor is not submitting medical treatment guidelines for the body part you have that coincides with his request, MTUS, chronic pain, ODG or ACOEM it may be difficult to get approvals through UR. He can also go outside of those guidelines if your condition or request does not fall within those guidelines.

It can be difficult to find a doctor to treat on a lien, especially now with the new rules. He can request a consult with a spine surgeon and send it to UR. However it sounds like you are having difficulties having him do that.

So to answer your question usually an RFA form from your doctor triggers UR, but not always. Claims adjuster can approve the request instead of sending to UR and also you may have been approved previously for a number of refills. Due to this you should ask the pharmacy to please run it through again if it is denied. Sometimes it takes time for the adjuster to approve or for it to be sent to UR. Some doctors do not even turn in the RFA form for several weeks. There are several reasons why you may be having difficulties.

Most companies have a internal UR appeals process after it is denied (not IMR). read the entire UR denial to see if this is an option. It is also important to read the reasons for the denial. Was it due to lack of information?

Good luck to you.