Time Requirements

(1) If a recommended treatment requires utilization review, then an employer shall submit the case to its utilization review organization within four (4) business days of the authorized treating physician’s notification of the recommended treatment, subject to subsection (5) of this Rule. The four (4) business day interval begins when the adjuster receives the medical record that corresponds in time to the date of the treatment request. The authorized treating physician’s notification of the recommended treatment to the employer shall, at a minimum, be in a form that confirms transmission by showing the time and date of receipt (e.g., facsimile). The employer shall notify all parties upon submitting the case to its utilization review organization and shall also, if requested, notify the Bureau. If the employer fails to comply with this subsection, then the employer may be subject to sanctions and/or civil penalties pursuant to Rule 0800-02-06-.10 of this Chapter. (2) The adjuster shall respond to the requesting provider within four (4) business days of a receipt of a request for treatment, referral, second opinion, or consult. The four (4) business GENERAL RULES OF THE WORKERS’ COMPENSATION PROGRAM CHAPTER 0800-02-06 UTILIZATION REVIEW day interval begins when the adjuster receives the medical record that corresponds in time to the date of the treatment request. If the adjuster does not approve the request within four (4) business days, the adjuster shall immediately send the request to the utilization review organization and notify all parties. The adjuster shall send to the utilization review organization all pertinent medical records corresponding to tests or treatments paid for by the insurer in the past twelve (12) months and any communications necessary for the utilization review organization to complete its determination. This shall include but not be limited to the Form C35-A containing current and complete information of the employer, the names and contact information for the injured worker, the adjuster, the adjuster’s supervisor, the compliance contact, and the attorneys. If there is no existing compliance contact email, the email for the adjuster’s supervisor, the office manager or other liaison shall be listed. The medical records shall be in chronological or reverse chronological order, free of duplicates, one-sided, free of fax confirmation sheets and free of billing statements. The organization of the medical records may be accomplished by the utilization review organization. The employer may be subject to sanctions and/or civil penalties pursuant to Rule 0800-02-06-.10 of this Chapter. (3) The utilization review organization shall render the determination and communicate the determination in writing to the authorized treating physician, employee and employer within seven (7) business days of receipt of the case from the employer, subject to subsection (5) of this Rule. If the determination is a denial, the utilization review report shall list all records and supplemental material reviewed by the utilization review organization. Upon request, the authorized treating physician or employee may obtain copies of any such records and supplemental material reviewed by the utilization review organization. The utilization review report shall also include an appeal form prescribed by the Bureau on which the utilization review organization shall identify the state file number associated with the claim for which treatment is being recommended, if any, and shall identify the utilization review organization’s certification number issued by the Bureau. If the utilization review organization fails to comply with this subsection, then the utilization review organization may be subject to sanctions and/or civil penalties pursuant to Rule 0800-02-06-.10 of this Chapter. (4) If a denial of the recommended treatment is appealed to the Bureau, then the employer as defined in these rules shall send a copy of the utilization review report and all records reviewed by the utilization review organization to the Bureau within five (5) business days of a request from the Bureau. (5) When the adjuster receives notification of an appeal being filed with the Bureau, the adjuster shall send to the Bureau, within (5) five business days, the same records as sent to the utilization review organization, including the medical records for the past twelve (12) months, the complete and current Form C35-A and the utilization review organization determination report, including the utilization review physician’s report containing the medical rationale for the denial. These shall be sent to the Bureau without duplicates or billing and fax records and in chronological or reverse chronological order, one-sided, containing the medical records, diagnostic studies, and medical correspondence for one calendar year before the date of the denial/modification determination. These record requirements may be met by sending the documents that were reorganized by the utilization review organization. The employer may be subject to sanctions and/or civil penalties pursuant to Rule 0800-02-06-.10 of this Chapter. (6) An approval of a recommended treatment by the employer’s utilization review organization shall be final and binding on the parties for administrative purposes. (7) When there is a dispute over a request for information, the following timeframes shall apply: (a) If the employer or utilization review organization does not possess all necessary information in order to evaluate the recommended treatment and render the utilization GENERAL RULES OF THE WORKERS’ COMPENSATION PROGRAM CHAPTER 0800-02-06 UTILIZATION REVIEW review determination, then it shall immediately make a written request for such information to the authorized treating physician, who shall comply with the written request within five business days of receipt of the written request. The time requirements in subsections (1)–(2) of this Rule shall be tolled until the employer or utilization review organization receives the necessary information or until the timeframe set forth in the preceding sentence expires, whichever occurs first. (b) Denials by a utilization review organization for inadequate information may be appealed pursuant to Rule 0800-02-06-.07, at which time the authorized treating physician shall submit all information deemed to be necessary by the Bureau. If the Bureau finds that the employer’s or utilization review organization’s request did not contain the necessary information, then the employer or utilization review organization may be subject to sanctions and/or civil penalties as set forth in Rule 0800-02-06-.10, at the discretion of the Administrator. In addition, if an authorized treating physician fails to cooperate and timely furnish all necessary information, records and documentation to an employer or utilization review organization, then the authorized treating physician may be subject to sanctions and/or civil penalties as set forth in Rule 0800-02-06-.10, at the discretion of the Administrator. (8) Employer’s obligations upon receipt of utilization review determination: (a) Within three (3) business days of receiving a utilization review determination that denies the recommended treatment, the employer as defined in Rule 0800-02-06- .02(8) shall give written notification to the employee and authorized treating physician as to whether the employer will authorize any of the recommended treatments that were denied by the utilization review organization and what, if any, conditions shall apply to such authorization. (b) If requested by the Bureau, within three (3) business days of receiving a utilization review determination that is either an approval or denial, the employer as defined in Rule 0800-02-06-.01 shall forward such determination to the Bureau. The employer shall also forward the notification described in subsection (6)(a) above, if applicable. (9) (a) The utilization review decision to deny a recommended treatment shall remain effective for a period of 6 months from the date of the decision without further action by the employer as defined in Rule 0800-02-06-.01(8) if the request is for the same treatment, unless there is a material change documented by the treating physician that supports a new review or other pertinent information that was not used by the utilization review organization in making the initial decision. This provision also applies to medication denials, or modifications. (b) A determination by the Bureau of a utilization review appeal, whether to uphold, overturn, or modify, shall be effective for six (6) months unless significant new material medical information, as determined by the Administrator or Administrator’s Designee, is presented to require a new utilization review determination by the utilization review organization or the Bureau on appeal.