Utilization Review Procedure & Appeals

Massachusetts Work Disability Attorneys

The Massachusetts workers’ compensation lawyers at Kantrovitz & Associates have helped numerous workers obtain needed medical treatment initially denied during utilization review. For over 25 years, we have guided employees through complex hurdles to appeal adverse determinations and get relief. Our Boston office serves injured workers throughout Massachusetts, Rhode Island, and New Hampshire.

Utilization Review (UR) Procedure

The Commonwealth of Massachusetts authorizes the Department of Industrial Accidents (DIA) to approve certain agents to conduct utilization review. 452 CMR § 6.00 requires workers’ compensation insurers to evaluate prospective medical services to be provided to injured workers within 12 weeks from the date of injury. During this period, UR agents follow strict guidelines to determine whether the proposed treatment is “reasonable, necessary, and effective.” If the service does not meet these clinical and quality assessment criteria, the agent will issue a denial or “adverse determination” following utilization review.

Treatment by Medical Providers

Before treating a job-related injury, physicians must fax a request for approval of the service to the UR provider. Doctors must wait for agents to evaluate the request according to treatment guidelines and issue a response before proceeding. The proposed service and all relevant medical information are reviewed by a doctor or specialist practicing in the same field as the requesting physician. The agent has two days from receiving the request to approve or deny the treatment.

Adverse Determination

The UR agent must provide written notice of an adverse determination, including the “clinical” reason for the denial. An adverse determination must clearly set forth the process to appeal. If the injured employee or the ordering medical provider believes that the denial merits immediate review, they may initiate an expedited appeal procedure by phone with a UR agent. Any request for review by the agent should be in writing and sent within 30 days of the determination. The agent must issue another determination no later than two days after the appeal was filed.

Appeals Procedure

Injured employees must “exhaust” their remedies by first seeking review by the agent. If the appeal yields a second adverse determination, MGL c. 152 § 10 allows them to file a claim with the DIA. The subsequent “conciliation” to resolve the dispute may require:

  • Informal meetings
  • Legal representation
  • DIA request for evidence
  • Affidavit of wage schedule
  • Medical reimbursement claims
  • Medical records involving liability
  • Review by Industrial Accident Board
  • Modification or termination of benefits

Appeals to the DIA must be timely filed on Employee Claim Form 110. Employees should use the form to file a claim for medical benefits, seek a higher amount of weekly compensation, or contest the termination of payment. This formally requests a hearing before an administrative law judge to obtain workers’ compensation benefits from the employer’s insurance company.

Recovering Compensation

If you are appealing an adverse determination for requested medical treatment, contact the Massachusetts workers’ compensation lawyers at Kantrovitz & Associates today. We have over 25 years’ experience obtaining the workers’ compensation benefits to which injured employees are entitled. At Kantrovitz & Associates, we use our extensive knowledge of the UR procedure and appeals process to seek the medical payments you need. We serve workers in Norfolk, Boston, Suffolk, Essex, Middlesex, Plymouth, and other counties. Call (800) 367-0871 to consult an experienced lawyer or contact us online.