UR Penalty Alert

Contrary to what the DWC indicated four months ago, the Division now says workers’ compensation claims administrators may be subject to utilization review penalties for failing to answer requests for treatment authorization in cases where the physician failed to check the "request for authorization" box on the Primary Treating Physician Progress Report (DWC PR-2 form).

To avoid penalty, claims operations and UR personnel need to carefully review PR-2 forms – including those where the "request for authorization" box is not checked — to determine whether treatment is requested.

The DWC continues to say that penalties are unlikely if a claims administrator fails to respond to a change in treatment included in a physician’s narrative that is submitted in lieu of a PR-2 if the narrative is not clearly marked at the top as a request for authorization.

BR/by