Heads Up: UR/IMR Regs Take Effect April 1

DWC’s revised UR, IMR and physician reporting regulations (Title 8 CCR §§ 9767.6, 9781, 9785, 9785.6, 9786, 9792.6 et seq, 9792.27.1, 9792.27.17) that were adopted late last year take effect on 4/1/26. The revisions were made to address concerns about UR delays and denials, strengthen regulatory oversight, expedite injured workers’ access to care and prescription drugs, and increase accountability for claims administrators and UR vendors. Here’s a rundown of many of the key elements within the regs:

• Several aspects of the UR process have been clarified.

• Requests for Authorization may be submitted by either a primary or secondary physician.
  • Barring a documented material change in the underlying facts, a UR denial remains in effect for 12 months for the same treatment request by the same physician or another physician in the requesting physician’s practice group.
  • If a claims administrator determines a prior denial still applies, they must issue a UR deferral notice; but if the physician claims circumstances have changed and provides supporting documentation, the request must still be reviewed by a UR physician.

• The timeframe for UR plan approvals has been extended.

• A 60-day extension after the initial 60-day review period has been added. If no action is taken after 120 days the plan will be deemed to have provisional approval.
  • If a plan is rejected or denied, the appeal timeline has been extended to 25 days.

• Documentation standards for UR decisions have been expanded.

• UR approval, denial, and modification notices must now include details on the timing of requests for supplemental information, exams, or consultations.
  • Denials or modifications must clearly explain the clinical rationale for the decision and note any missing information needed to determine medical necessity.
  • Reviewing physicians must also address situations in which the requesting physician argues that guideline prerequisites should be bypassed.
  • The UR organization must be accredited by the Utilization Review Accreditation Commission (URAC) and identified in the determination letter.

• The regs implement LC §4610(b) allowing treating physicians to provide medically necessary treatment in the first 30 days after injury without prior authorization if the body part or condition has been accepted as compensable and the treatment is consistent w/the MTUS.

• Physicians must still submit both a Doctor’s 1st Report (5021) and an RFA concurrently.
  • The 30-day rule does not apply to certain services that will still require prospective UR, (e.g., non-exempt drugs, non-emergency surgery, psych treatment, home health care, advanced imaging other than X-rays, high-cost DME, electrodiagnostic tests, and spinal injections.)
  • Claims administrators can retrospectively review exempt treatment and request a change of physician or remove the provider from the MPN if a physician demonstrates a “pattern and practice” of providing care inconsistent with the MTUS guidelines. 

• “Exempt,” “Special Fill,” or “Perioperative” drugs may still be dispensed without prospective UR, while UR decisions on “Non-Exempt” drugs still need to be made within 5 business days, but that timeline cannot be extended and requests for additional info must be made within 4 business days.

• To accelerate the resolution of prescription drug disputes, if a dispute involves only formulary drugs, the injured worker must file for IMR within 10 days rather than 30; the claims administrator must submit documentation to the IMR organization within 10 days; and the IMR decision must be issued within 5 business days after the application and the supporting documentation are received.

• Several changes will impact claims administrator interactions w/their MPNs.

• Claims administrators must provide the selected physician with relevant medical records—including diagnostic and lab results—within 20 days of their selection.
  • Claims administrators must provide MPN physicians with administrative information such as the MPN ID number and correct submission contacts for RFAs and billing.

• Changes have been made affecting physician reporting.

• Physician may transmit reports electronically, including via encrypted email or EDI.
  • Physicians providing first aid will now need to complete a Doctor’s 1^st Report (5021).

• DWC’s UR oversight program has been completely overhauled with much higher penalties.

• UR plans that modify or deny treatment must confirm their URAC accreditation and report material changes (such as switching UR vendors or changing medical directors) within 30 days.
  • The AD has expanded authority to approve, conditionally approve, place on probation, suspend, or revoke UR plans for noncompliance.
  • The UR “performance rating” audit system, which allowed entities scoring above 85% to avoid non-mandatory penalties, has been eliminated.
  • There will be no automatic waivers, and violations may result in major penalties, even for administrative errors. Many penalties have increased significantly, including:

• $30K for operating w/o an approved UR plan.
  • $25K for violations involving physician independence in UR decisions
  • $10K for failing to maintain URAC accreditation.
  • $10K for failing to discuss and/or document attempts to discuss reasonable options for a care plan with the requesting physician prior to a denial or discontinuing care in case of concurrent review
  • $5K for failing to comply with UR deferral requirements
  • $3K for improperly requiring prospective UR during a 30-day exemption period
  • $500/day up to $20K for failing to timely serve the AD with documentation of compliance
  • Timeliness violations now accrue, which will increase daily or hourly penalties
  • The AD may impose penalties of up to $50K for serious infractions

Bottomline: The expanded penalties and elimination of performance-rating waivers require compliance at the individual transaction level so claims administrators and UR vendors need to ensure compliance with the new UR documentation standards, the prescription drug review timelines, and the 30-day treatment exemption requirements. The effective date is just two weeks away so you should review procedures with your UR vendors, confirm that your UR plan has been approved by the DWC, and ensure that your staff is trained on the new requirements before the April 1 effective date. More details are in the final regs which are posted here.