Maximus Issues Deficient Notices of IMR Assignment & Request for Information

This week, Maximus Federal Services, which is under contract with the DWC to conduct workers’ compensation independent medical reviews, began issuing a revised Notice of Independent Medical Review Assignment and Request for Information that deletes critical information that claims administrators need in order to respond to the requests. Specifically, the notice fails to include the following details, required under CCR §9792.10.4 (b), (c) and (d):

   (b) Identification of the disputed medical treatment, including the date of the request for authorization, the name of the requesting physician, and the date of the claims administrator’s utilization review decision.

   (c) The date the Application for Independent Medical Review, DWC Form IMR, was received by the Independent Review Organization.

   (d) A statement advising whether the independent medical review will be conducted on a regular or expedited basis.

The notice states that the claims administrator must provide Maximus with all the documents it lists within 15/12 days of the notice and that Maximus will issue a letter with its decision within 45 days from the date of the notice. However, many claims involve multiple UR determinations, so claims administrators will not be able to submit the records requested unless Maximus notifies them which determination is disputed. We believe that Maximus must send a corrected complete notice without delay to replace each deficient notice and start the 15/12 day clock.

It is not clear why Maximus has switched to a deficient notice. The Institute has attempted to contact Dr. Weiss, the Maximus Medical Director who signed the new letter, but without success, so we have alerted the DWC Acting Administrative Director and asked her to contact Maximus and direct them to correct the problem as soon as possible. Attached are redacted samples of the original notice and the new deficient notice.

Stay tuned. The Institute will keep you posted as additional information becomes available.

BR/by
Attachments

Click here: Maximus Notification #1

Click here: Maximus Notification #2