GENEX California Utilization Review

UR Regulation

The California Utilization Review regulations became effective on September 22, 2005.

The California Division of Workers’ Compensation also approved Utilization Review enforcement regulations. The regulations were effective June 7, 2007. 

Under the new regulations utilization review agencies are subject to routine investigations at least once every three years. The CA Division of Workers’ Compensation may also conduct targeted investigations based on any possible violation
of Labor Code section 4610 or sections 9792.6 through 9792.12.

Administrative penalties may be assessed for any failure to comply with Labor Code section 4610, or sections 9792.6 through 9792.12 of Title 8, California Code of Regulations. 

Claims organizations making utilization review decisions will also be subject to penalties should they fail to follow the regulations. Therefore, it is important to note if the claims examiner authorizes treatment without the use of a utilization review organization (URO);they will be accountable for the timeline and notification requirements. The regulations define required timelines and conditions which must be met when requests
for authorization are received whether by the employer, claims administrator or utilization review organization (URO).