An injured worker, or someone she or he designates, may request independent medical review (IMR) if utilization review (UR) denies or modifies a requested medical treatment for an accepted claim. The claims administrator must send the injured worker a notice of the UR denial along with a partially completed IMR request form. To request IMR, the worker must submit the signed application for IMR and mail the original signed Application for Independent Medical Review and a copy of the utilization review denial of treatment within 30 days of receiving the utilization denial:
To date, when an IMR application is received without a copy of the UR denial, a reminder letter is sent to the worker requesting the UR denial and allowing an additional 15 days to comply with this requirement.
As of March 1, 2014, a revised IMR application must be sent by the claims administrator to the injured worker. The revised form now clearly advises that the copy of the UR denial must be included with the IMR application. Therefore, beginning April 1, 2014, DWC will cease issuing reminder letters if the UR denial is not included with the submittal of an IMR application and will instead advise the worker that the IMR application is ineligible.
Similarly, when a provider submits a request for independent bill review (IBR), the provider is required to include and index the following documents:
- The original billing itemization and original supporting documentation
- The explanation of review provided in response to the original billing
- The request for second bill review and original documentation supporting second review
- The explanation of review provided in response to the second bill request
- If applicable, the relevant contract provisions for reimbursement rates.
To date, when a request for IBR is received without the required documentation, a reminder letter is sent to the provider requesting the documentation and allowing an additional 15 days to comply with this requirement. The final IBR regulations became effective on Feb. 13, 2014. For IBR requests that are received on or after Feb. 13, 2014, DWC will cease issuing reminder letters if the required documentation is not included with the submittal of an IBR application and will instead advise the provider that the IBR request is ineligible.
These changes are being made in an effort to better serve the public by streamlining the process and focusing efforts on issuing determinations in a timely manner.