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California Orthopaedic Association |
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Workers’ Compensation Resource Center for COA Members
Utilization Review Appeals Process
To assist orthopaedic surgeons in navigating California’s Workers’ Compensation Utilization Review system, COA has developed this Utilization Review Resource Packet to assist them in understanding the required utilization review process, the timeframes under which the reviewer must make decisions, potential rationales on which to base your appeal, and a sample appeal letter.
The following information is included: Utilization Review Authorization Flow Chart DWC Utilization Review – Frequently Asked Questions DWC DRAFT Form – Authorization for Medical Treatment Labor Code Section 4610 – Utilization Review Process DWC Regulation 9792.20 Medical Treatment Utilization Schedule—Definitions DWC Regulation 9792.6 – Utilization Review Standards—Definitions DWC Regulations 9792.11-15 – Utilization Review Fines and Penalties Labor Code Sections 4062 and 4062 (b) DWC Utilization Review Complaint Form
In addition, COA will serve as a resource for locating practice guidelines and/or evidenced-based literature on specific topics that could be helpful to members when preparing their appeal. This resource will focus on orthopaedic areas which are most controversial or subject to denials (e.g., post-surgical rehabilitation services). This COA service can be accessed by sending an e-mail to: coa1@pacbell.net or faxing a request to COA: 916-454-9882 fax and providing information on the specific appeal. |
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