DE OWC Receives Utilization Review Requests


Dover, DE (CompNewsNetwork) - The Office of Workers' Compensation (OWC) has been receiving an ever increasing number of utilization review (UR) requests for "prospective" treatment; however, the case report and medical documentation does not always identify the "proposed" treatment.  The DE Workers' Compensation Health Care Payment System (HCPS) allows "prospective" UR requests only when the UR applies to "proposed" treatment.  Reviewers cannot make assumptions on how an injured worker will respond to treatment that has not occurred or what treatment a health care provider might recommend.

Below is the citation from 19 Delaware Code, Section 2322F(j) of the Workers' Compensation Act, as well as 19 De Admin Code 1341, Section 5.4.2 from the regulations regarding utilization review in the HCPS.

Pursuant to 19 Delaware Code, Section 2322F(j),

"...An employer or insurance carrier may engage in utilization review to evaluate the quality, reasonableness and/or necessity of proposed or provided health care services for acknowledged compensable claiims..."

In addition, 19 De Admin Code 1341, Section 5.4.2 says the following,

"If the claim is denied by an employer or insurance carrier for non-compliance with any applicable Practice Guidelines, only the first bill for such treatment, and not all subsequent bills for the same service, need be denied and referred to utilization review."

Please make a note that the OWC will only process a "prospective" utilization review request when the completed request pertains to a certified health care provider's "proposed or provided health care services" for one of the 6 practice guidelines - cervical (effective 6/1/10), shoulder, chronic pain, low back, carpal tunnel, and cumulative trauma disorder.  The UR request must clearly document that a health care provider proposed the health care service.  In addition, once the employer or insurance carrier denies a bill for ongoing treatment and sends the UR request to the OWC, then "only the bill for such treatment, and not all subsequent bills for the same service, need be denied and referred to utilizatoin review," pursuant to 19 De Admin Code 1341, Section 5.4.2.
For Supplemental Utilization Reviews:

The Office of Workers' Compensation (OWC) allows employers or insurance carriers ("requesters") to submit supplemental material versus a whole new UR package when they request a supplemental utilization review for the same person and date of injury.  However, two important caveats exist.

OWC only retains complete UR packages for 1 year and then purges the medical records from the file.  "Requesters" must submit a complete original request package for any supplemental UR requests that involve an original request more than one year old.

Certains circumstances may exist when the original review complany may not perform the supplemental review.

In either case, "requesters" will need to submit a complete UR package for a supplemental UR request.  

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