UTILIZATION REVIEW

PLAN

CITY OF LOS ANGELES

EFFECTIVE DATE:

July 01, 2010

Revised July 30, 2010

TABLE OF CONTENTS

UTILIZATION REVIEW PLAN

SECTION 1

DEFINITIONS

DEFINITIONS

UTILIZATION REVIEW

“ACOEM Practice Guidelines” means the American College of Occupational and Environmental Medicine’s Occupational Medicine Practice Guidelines, Second Edition.

“Authorization” means assurance that appropriate reimbursement will be made for an approved specific course of proposed medical treatment to cure or relieve the effects of the industrial injury pursuant to section 4600 of the Labor Code, subject to the provisions of section 5402 of the Labor Code.

“Concurrent Review” means utilization review conducted during an inpatient stay.

“Emergency health care services” means health care services for a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonable be expected to place the patient’s health in serious jeopardy.

“Expert Reviewer” means a medical doctor, doctor of osteopathy, psychologist, acupuncturist, optometrist, dentist, podiatrist or chiropractic practitioner licensed by any state or the District of Columbia, competent to evaluate the specific clinical issues involved in the medical treatment services and where these services are within the individual’s scope of practice.

“Immediately” means within 24 hours after learning the circumstances that would require an extension of the timeframe for decisions.

“Medical Necessity” means what is considered ‘medically necessary’, ‘reasonable and necessary’, or ‘medically appropriate’. The procedure, test or service is: necessary to cure or relieve the effects of the injury; safe and effective; consistent with the recipient’s symptoms, diagnoses, condition, or injury; likely to provide the intended health result; likely more effective than more conservative or less costly services; provided not only as a convenience to the patient or the provider; represents a benefit that outweighs any risk; reasonably expected to diagnose, correct, cure, alleviate or prevent worsening of illnesses or injuries; enables a patient to make reasonable progress in treatment; and meets the prevailing standard for medical care as outlined in the ACOEM or other accepted evidenced-based guidelines (unless the treating physician has presented reasonable information to explain why the particular patient does need atypical, unexpected treatment).

“MTUS” means the Medical Treatment Utilization Schedule set forth in 8 CCR 9792.20 through 9792.23.

“Prospective Review” means any utilization review conducted, except for during an inpatient stay, prior to the delivery of the requested medical services.

“Request for Authorization” means a written confirmation of an oral request for a specific course of proposed medical treatment pursuant to Labor Code section 4610 (h) or a written request for a specific course of proposed medical treatment. An oral request for authorization must be followed by a written confirmation of the request within seventy-two (72) hours. Both the written confirmation of an oral request and the written request must be set for on the doctor’s First report of Occupational Injury of Illness, Form DLSR Form PR-3, as contained in section 9785.2, or in narrative form containing the same information required in the PR-2 form. If a narrative format is used, the document shall be clearly marked at the top that it is a request for authorization.

“Retrospective Review” means utilization review conducted after medical services have been provided and for which approval has not already been given.

“Reviewer” means a medical doctor, doctor of osteopathy, psychologist, acupuncturist, optometrist, dentist, podiatrist or chiropractic practitioner licensed by any state or the District of Columbia, competent to evaluate the specific clinical issues involved in the medical treatment services and where these services are within the individual’s scope of practice.

“Utilization review process” means utilization management functions that prospectively, retrospectively or concurrently review and approve, modify, delay or deny, based in whole or in part on medical necessity to cure or relieve, treatment recommendations by physicians, as defined in Labor Code section 3209.3, prior to, retrospectively, or concurrent with the provision of medical treatment services pursuant to Labor Code section 4600.

“Written” includes a facsimile as well as communications in paper form.

SECTION 2

PRIOR AUTHORIZATION

PROGRAM

Section 2 Revised 07/30/10

City of Los Angeles

PERSONNEL DEPARTMENT

WORKERS’ COMPENSATION DIVISION

700 EAST TEMPLE STREET

LOS ANGELES, CA 90012

CALIFORNIA

ANTONIO R. VILLARAIGOSA

MAYOR

June 25, 2010

SUBJECT: CITY OF LOS ANGELES “PRIOR AUTHORIZATION PROGRAM”

INFORMATION ABOUT UTILIZATION REVIEW OF TREATMENT REQUESTS

PRIOR AUTHORIZATION PROGRAM

The City of Los Angeles has implemented a Prior Authorization Program. The Prior Authorization Program allows providers in the City’s First Care Panel to provide routine medical procedures on accepted and delayed claims without Utilization Review based on their adherence to the Medical Treatment Utilization Schedule (MTUS) and evidence-based medicine. All treatment must follow the Title 8 CCR § 9792.20-9792.22 MTUS criteria.

The Prior Authorization Program will include the following procedures or ancillary services:

Up to 12 Physical Therapy Sessions

Up to 12 Chiropractic or Acupuncture Sessions

Routine Office Visit and Follow Ups

Specialty Referral

Initial MRI or CT Scan

EMG/NCS

Plain View X-Rays

90-days prescription drugs per Pharmacy Benefit Management (PBM) formulary

Basic DME: Splits, Crutches, Braces, cane, walker, standard wheelchair rental, off the shelf braces, walking boots, slings, hot and cold packs.

No provider notification letters will be sent by the City claims administrators or designated Utilization Review Organization for the procedures or services that fall under this Program.

PLEASE NOTE: All of the above procedures and ancillary services must be provided by the City of Los Angeles’ Contracted Managed Care Providers on the attached list.

Prior Authorization Program

Page 2

The City of Los Angeles is committed to providing prompt and courteous service to our injured employees. Additionally, we want to ensure compliance with all State-mandated laws LC§ 4610 and rules and regulations Title 8, California Code of Regulations § 9792.8, §9792.9 and §9792.10. Due to the complexities of Utilization Review and the necessity of providing prompt and appropriate treatment to our injured employees, the City of Los Angles has filed the “Prior Authorization Plan” to ensure that all city workers receive prompt, appropriate and courteous treatment with no delays.

Treatment outside of the “Prior Authorization Plan” must go through Utilization Review. The City of Los Angeles, as of July 1, 2010 will be contracting with AON eSolutions and their vendor Prime Care for all Utilization Review functions. Prime Care utilizes clinical review criteria recommended by the Clinical Review Committee and approved by the Prime Care Medical Director Lester L. Sacks, MD. The current clinical review criteria utilized by Prime Care is:

1. State of California Medical Treatment Utilization Schedule §9792.21
2. American College of Occupational and Environmental Medicine’s Occupational Medicine Practice Guidelines, Second Edition (ACOEM)
3. The Official Disability Guidelines (ODG)
4. Medical Disability Advisor (Presley-Reed, M.D.)
5. Interqual

Additionally, the law allows the use of other evidence-based protocols when evaluating the need for medical treatment.

We will evaluate medical treatment on a prospective, concurrent, and retrospective basis. By using the enclosed Medical Treatment Authorization form, you will be assisting us with expediting all of your treatment requests. Please make copies of this form for your convenience and use it for all future requests.

The authorization request form should be faxed directly to our UR Units listed below. We ask that you complete the form in its entirety and please include prior treatment received by injured employee to include CPT and/or ICD.9 codes, and include a copy of the most recent (within the last 20 days of physical examination) PR-2 or narrative report and any radiology readings in your possession. Please be specific in your request(s). Failure to receive these supporting documents with your treatment request may result in delayed treatment authorization. Please continue to mail all original reports directly to the claims analyst.

Civilian Claims: FAX (213) 473-3377 Tristar: Fire and Police Claims, FAX (626) 407-0435

If you have any questions regarding this Program, please feel free to call Principal Worker’s Compensation Analyst Diana Tang at (213) 473-3420, or Senior Workers’ Compensation Analyst Irene Herrera, at (213) 473-3351 or Tristar Manager Sheri Shorten at (626) 407-0400, ext. 2411.

Prior Authorization Program

Page 3

NOTIFICATION PROCEDURES

1. Mass Mailing

All 1^st Care Panel Providers and initial treating physicians have been provided with the City’s Prior Authorization Program.

2. 3-Point Contact:

a) The Claims staff will discuss the City’s Prior Authorization Program when contacting

the Primary Treating Physician (PTP) and the employee as part of the 3-point

contact.

b) The Claims Staff will:

i) Ascertain whether the PTP’s office is aware of the Prior Authorization

Program, and if not, an explanation of the “Prior Authorization Program” will

be made;

ii) Explain the City’s Return to Work program; and

iii) Send the PTP a copy of the City of Los Angeles’ Prior Authorization Program.

iv) Send the employee a copy of the City of Los Angeles’s Prior Authorization Program.

3. City of Los Angeles Utilization Review Plan is posted on the PrimeCare Health Services Group, Inc. website at: PRIMECAREMC.COM

UTILIZATION REVIEW PROCEDURES

1. No Written Request: When a treating physician provides treatment/services

that fall within the “Prior Authorization Program” without submitting a written request to UR of pre-authorization: (1) the treatment/services is automatically authorized; and (2) UR does not need to issue UR determination notices indicating the treatment/service has been authorized.

2. Written Requests: If a treating physician submits a written request for pre-authorization, despite the fact that the treatment/service falls within the Prior Authorization Program, the City claims administrators will respond to the request in the form of a generic “Prior Authorization Approval Notice Letter”, which notifies the provider that this request is automatically approved under the City of Los Angeles’ Prior Authorization Program, and that, in the future they do not have to send a request for authorization for those treatments authorized in the Prior Authorization Program. The City’s claims administrators will send provider copy of Prior Authorization Program.

City of Los Angeles

Contracted Managed Care Providers

For MRI or CT Scan

For Physical Therapy, Occupational Therapy or Chiropractic Visits

Align Networks

For Medication and Durable Medical Equipment

Cypress Care

(www.cypresscare.com)

INITIAL NOTIFICATION LETTER TO FIRST CARE PANEL

City of Los Angeles

PERSONNEL DEPARTMENT

WORKERS’ COMPENSATION DIVISION

700 EAST TEMPLE STREET

LOS ANGELES, CA 90012

CALIFORNIA

ANTONIO R. VILLARAIGOSA

MAYOR

June 25, 2010

Dear Medical/Service Provider:

SUBJECT: CITY OF LOS ANGELES “PRIOR AUTHORIZATION PROGRAM”

INFORMATION ABOUT UTILIZATION REVIEW OF TREATMENT REQUESTS

PRIOR AUTHORIZATION PROGRAM

On July 1, 2010 the City of Los Angeles will implement a Prior Authorization Program. The Prior Authorization Program allows providers in the City’s First Care Panel to provide routine medical procedures on accepted and delayed claims without Utilization Review based on their adherence to the Medical Treatment Utilization Schedule (MTUS) and evidence-based medicine. All treatment must follow the Title 8 CCR § 9792.20-9792.22 MTUS criteria.

The Prior Authorization Program will include the following procedures or ancillary services:

Up to 12 Physical Therapy Sessions

Up to 12 Chiropractic or Acupuncture Sessions

Routine Office Visit and Follow Ups

Specialty Referral

Initial MRI or CT Scan

EMG/NCS

Plain View X-Rays

90-days prescription drugs per Pharmacy Benefit Management (PBM) formulary

Basic DME: Splits, Crutches, Braces, cane, walker, standard wheelchair rental, off the shelf braces, walking boots, slings, hot and cold packs.

No provider notification letters will be sent by the City claims administrators or designated Utilization Review Organization for the procedures or services that fall under this Program.

PLEASE NOTE: All of the above procedures and ancillary services must be provided by the City of Los Angeles’ Contracted Managed Care Providers on the attached list.

Prior Authorization Program

Page 2

The City of Los Angeles is committed to providing prompt and courteous service to our injured employees. Additionally, we want to ensure compliance with all State-mandated laws LC§ 4610 and rules and regulations Title 8, California Code of Regulations § 9792.8, §9792.9 and §9792.10. Due to the complexities of Utilization Review and the necessity of providing prompt and appropriate treatment to our injured employees, the City of Los Angles has filed the “Prior Authorization Plan” to ensure that all city workers receive prompt, appropriate and courteous treatment with no delays.

Treatment outside of the “Prior Authorization Plan” must go through Utilization Review. The City of Los Angeles, as of July 1, 2010 will be contracting with AON eSolutions and their vendor Prime Care for all Utilization Review functions. Prime Care utilizes clinical review criteria recommended by the Clinical Review Committee and approved by the Prime Care Medical Director Lester L. Sacks, MD. The current clinical review criteria utilized by Prime Care is:

6. State of California Medical Treatment Utilization Schedule §9792.21
7. American College of Occupational and Environmental Medicine’s Occupational Medicine Practice Guidelines, Second Edition (ACOEM)
8. The Official Disability Guidelines (ODG)
9. Medical Disability Advisor (Presley-Reed, M.D.)
10. Interqual

Additionally, the law allows the use of other evidence-based protocols when evaluating the need for medical treatment.

We will evaluate medical treatment on a prospective, concurrent, and retrospective basis. By using the enclosed Medical Treatment Authorization form, you will be assisting us with expediting all of your treatment requests. Please make copies of this form for your convenience and use it for all future requests.

The authorization request form should be faxed directly to our UR Units listed below. We ask that you complete the form in its entirety and please include prior treatment received by injured employee to include CPT and/or ICD.9 codes, and include a copy of the most recent (within the last 20 days of physical examination) PR-2 or narrative report and any radiology readings in your possession. Please be specific in your request(s). Failure to receive these supporting documents with your treatment request may result in delayed treatment authorization. Please continue to mail all original reports directly to the claims analyst.

Civilian Claims: FAX (213) 473-3377 Tristar: Fire and Police Claims, FAX (626) 407-0435

If you have any questions regarding this Program, please feel free to call Principal Worker’s Compensation Analyst Diana Tang at (213) 473-3420, or Senior Workers’ Compensation Analyst Irene Herrera, at (213) 473-3351 or Tristar Manager Sheri Shorten at (626) 407-0400, ext. 2411.

Sincerely,

Dawn Alvarado

Workers’ Compensation Administrator

Enclosure: Medical Treatment Authorization Form

City of Los Angeles

Contracted Managed Care Providers

For MRI or CT Scan

For Physical Therapy, Occupational Therapy or Chiropractic Visits

Align Networks

For Medication and Durable Medical Equipment

Cypress Care

(www.cypresscare.com)

Date:

SENT VIA FAX TO REQUESTING PROVIDER: Fax #

Dear PROVIDER NAME

The REQUEST DATE request for medical treatment for CLAIMANT NAME was received on DATE REQUEST RECEIVED. The request has been reviewed in accordance with the City of Los Angeles/CIDs Utilization Review Program.

The following procedure(s) has been authorized for reimbursement per the prevailing California Official Medical Fee Schedule (OMFS), or Contractual Agreement, whichever is less. Payment is subject to applicable statutes and regulations, including, but not limited to, Labor Code §139.3 and 139.31.

This certification will be valid for 60 days from the date of this letter.

Sincerely,

Analyst Name

City of Los Angeles, Workers’ Compensation Division

700 E. Temple Street Room 210

Los Angeles, CA 90012

Utilization Review Unit Fax: 213-473-3377

cc: Servicing Provider Name; Fax #

Prescribing Physician Name; Fax #

NOTICE TO PROVIDER IF REQUEST MADE IS CONTAINED WITHIN THE PRIOR AUTHORIZATION PROGRAM

City of Los Angeles

CALIFORNIA PERSONNEL DEPARTMENT

WORKERS’ COMPENSATION DIVISION

700 E. TEMPLE ST., ROOM 210

LOS ANGELES, CA 9 0012

ANTONIO VILLARAIGOSA

MAYOR

Date

Provider

Address

City, State Zip Code

PRIOR AUTHORIZATION APPROVAL NOTICE LETTER

Employee: Date of Request:

Claim No: Provider:

Employer: City of Los Angeles Date of Injury:

Dear provider name :

Your request for medical treatment has been reviewed in accordance with the City of Los Angeles’ Prior Authorization Program, which was implemented on July 1, 2010 and approved by the Division of Workers’ Compensation. Your request is automatically approved as it meets the criteria for automatic approval established under the City of Los Angeles’ Prior Authorization Program. In the future you do not have to send a request for treatment if it falls within the criteria established in our Prior Authorization Program.

City of Los Angeles’s Prior Authorization Program is as follows:

PRIOR AUTHORIZATION PROGRAM

On July 1, 2010 the City of Los Angeles implemented a Prior Authorization Program. The Prior Authorization Program allows physicians in the city’s First Care Panel to provide routine medical procedures on accepted and delayed claims without utilization review based on their adherence to the MTUS and evidence-based medicine. All treatment must follow the Title 8 CCR § 9792.20-9792.22 MTUS criteria.

The Prior Authorization Program will include the following procedures or ancillary services:

Up to 12 Physical or Occupational Therapy Sessions

Up to 12 Chiropractic or Acupuncture Sessions

Routine Office Visit and Follow Ups

Specialty Referral

Initial MRI or CT

EMG/NCS

Plain View X-Rays

90-days prescription drugs per PBM formulary

Basic DME: Splits, Crutches, Braces, cane, walker, standard wheelchair rental, off the shelf braces, walking boots, slings, hot and cold packs

No provider notification letters will be sent by the City claims administrators or designated URO for those procedures which fall under this program.

PLEASE NOTE: All of the above procedures and ancillary services must be provided by the City of Los Angeles’ Contracted Managed Care Providers on the attached list.

City of Los Angeles’ Contracted Managed Care Providers are:

For MRI or CT:

For Physical Therapy, Occupational Therapy or Chiropractic Visits:

Align Networks

When the provider or doctor calls you for authorization, simply refer them to the 4 ways of making a referral:

For Medication and Durable Medical Equipment:

Cypress Care

Website – www.cypresscare.com

SECTION 3

UTILIZATION REVIEW PLAN

Utilization Review Policy and Procedure

Prospective, Concurrent and Retrospective Review

Pursuant to Labor Code Section 4610, PrimeCare Health Services Group, Inc. (hereinafter referred to as PCHSG) on behalf of its clients, will conduct Utilization Review consistent with the regulations contained in Labor Code Section 4610 and Title 8. Industrial Relations, Division 1. Department of Industrial Relations, Chapter 4.5 Division of Workers’ Compensation, Subchapter 1. Administrative Director – Administrative Rules, Article 5.5.1 Utilization Review Standards and 8 CCR Section 9792.6 et seq (incorporated herein in its entirety by this reference).

This Utilization Review Process will be coordinated through the services of Utilization Review Nurses, Physician Advisors, Medical Advisors and/or the Medical Director. The ACOEM Practice Guidelines and other established evidence based medical treatment guidelines, including but not limited to the Medical Disability Advisor (Presley-Reed, M.D.), the Official Disability Guidelines (O.D.G.) or Interqual will be applied to cases where the ACOEM Practice Guidelines do not cover the specific injury sustained by the injured employee. Subscriptions to each of the guidelines indicated above have been secured which provide updates as developed. These updates are incorporated into the review process as they are issued. Review criteria shall be updated automatically to include any and all changes in said guidelines upon notification of any such published changes. PCHSG shall contact each of the above named publishers a minimum every 6 months to determine if any changes have occurred and obtain said information immediately. These guidelines and procedures will be in accordance with all the rules, regulations, laws and guidelines of the State of California, as adopted by the California governing bodies.

It is the intent of the UR plan to utilize Best Practices in the context of making certain that all UR decisions contain appropriate and complete explanations and definitions of the evidence based guidelines utilized in the decision making process in order to eliminate any confusion or ambivalence. For example, Best Practices will include such things as the elimination of the incorrect use of regulatory definitions, failure to include complete explanations within the procedures, or provision of inaccurate letters in order to avoid confusion with the procedures and non-compliance of the UR regulation requirements.

(8 CCR §9792.10(b)(1), §9792.12(a)(11))

Best Practices in this context should not be confused with the term Best Practices as it is applied to appropriate medical care.

The following Medical Treatment Utilization Schedule (MTUS) are utilized in making Utilization Review decisions and have been included in the Utilization Review Plan Effective June 1, 2007 as amended. The MTUS and its updates are used as the primary guideline in making Utilization Review decisions and is considered presumptively correct. (8 CCR §9792.8(a)(1)):

Article 5.5.2 Medical Treatment Utilization Schedule, inclusive of all Sections:

Section 9792.20 – Medical Treatment Utilization Schedule – Definitions

(a) – (l) – inclusive of all subsections

Section 9292.21 – Medical Treatment Utilization Schedule

(a) – (c) – inclusive of all subsections

Section 9792.22 – Presumption of Correctness, Burden of Proof and Strength

of Evidence

(a) – (c) – inclusive of all subsections

Section 9792.23 – Medical Evidence Evaluation Advisory Committee

(a) – (f) – inclusive of all subsections

Regulations Effective May, 2007

The following Medical Treatment Utilization Schedule (MTUS) are utilized in making Utilization Review decisions and have been included in the Utilization Review Plan Effective July 18, 2007 as amended. The MTUS and its updates are used as the primary guideline in making Utilization Review decisions and is considered presumptively correct. (8 CCR §9792.8(a)(1)):

Article 5.5.2 Medical Treatment Utilization Schedule, inclusive of all Sections:

Section 9792.24 – Special Topics – Inclusive of all subsections

Section 9792.24.1 – Acupuncture Medical Treatment Guidelines

(a) – (e) – inclusive of all subsections

Section 9792.24.2 – Chronic Pain Medical Treatment Guidelines

(a) – (e) – inclusive of all subsections

Regulations Effective July 18, 2009

1. Upon receipt of the request for Utilization Review from the claims office the Utilization Review Process is initiated within one (1) business day. Where the request is submitted by the patient, attending provider, or facility rendering service authorization to proceed with the Utilization Review is first confirmed with the claims examiner or claims staff and the process is initiated within one (1) business day of receipt of confirmation.

A. When the UR Nurse receives a telephone call or written correspondence from the patient, injured worker, physician, licensed provider, responsible patient representative, family member, adjuster, facility or any reasonably reliable source requesting authorization for a proposed treatment the UR Nurse, the Medical Director, or other Medical Advisor shall obtain the medical information necessary to make a determination to certify, delay, modify or deny a request for services).

B. Authorization of requested service means the assurance that the appropriate reimbursement will be made for an approved specific course of proposed medical treatment to cure or relieve the effects of the industrial injury pursuant to section 4600 of the Labor Code.

C. In the event there is a requirement for Emergency health care services, defined as health care services for a medical condition manifesting itself

by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to place the patient’s health in serious jeopardy, the Utilization Review Process shall be initiated within one (1) business day after notification of such an event. Utilization Review determinations shall be made in accordance with Section 4 B or 4 C of the Utilization Review Plan. Failure to obtain prior authorization for emergency health care services shall not be an acceptable basis for refusal to cover medical services provided to treat and stabilize an injured worker presenting for emergency health care services. Documentation for emergency health care services shall be made available to the claims administrator upon request.

2. Information collected will include:

Patient name, address, phone number, date of birth, insurance ID number, employee name, social security number, address, phone number, employer group, treating physician, address, phone number and tax ID number, facility name, address phone number and tax ID number, diagnosis, proposed treatment plan, and medical information to support the treatment plan. Data is entered into a secure computer application and information is shared with all disciplines within the UR department that have a need to know in order to complete the review process.

A. When conducting prospective review, concurrent review or retrospective

review, the UR Nurse:

(1) Will collect only the information necessary to certify the admission, procedure or treatment, length of stay, or frequency or duration of services;

(2) Will request from hospitals, physicians, and other providers the numerical code of the diagnosis (ICD-9) or procedure to be considered for certification;

(3) May request copies of all medical records on all patients reviewed;

(4) Requires only the section(s) of the medical record necessary in that specific case to certify medical necessity or appropriateness of the admission or extension of stay, frequency or duration of service, or length of anticipated inability to return to work; and

B. In situations where there is insufficient information to conduct the review, the UR Nurse will make at least two (2) attempts to notify the patient, attending

provider, provider, or facility rendering service (as applicable), within the UR

process timeframes required by law, of the need for additional information, the

information needed, and the method by which to submit it.

C. If the patient, attending provider, provider, or facility rendering service does not give medical information for pre-certification determination, then the case is referred to our Medical advisor for a non-certification due to lack of information. Our non-certification correspondence indicates reason for non- certification and is accompanied with our appeals process and forwarded to the patient, attending provider, provider, or facility rendering service within one (1) business day of the determination. If the treatment plan is non- certified for lack of information and the patient, attending provider, provider, or

facility rendering service subsequently provides complete clinical information within the allowable timeframe, the UR Nurse can certify the treatment plan. If the UR Nurse is unable to certify the treatment plan, the original Medical advisor who denied the treatment plan for lack of information can re-review the treatment plan to make a determination.

3. The Initial Clinical Review is conducted by a UR Nurse who reviews the proposed treatment plan for medical appropriateness and necessity using an ACOEM guideline or

other medically recognized criteria when an ACOEM guideline does not exist. If the treatment plan is not supported by the initial clinical information provided, or if the provider is unable to be contacted, then the case will be referred for Physician Peer Clinical Review within 24 hours. No person other than a licensed physician who is

competent to evaluate the specific clinical issues involved in the medical treatment services, and where these services are within the scope of the physician’s practice, requested by the physician may modify, delay, or deny requests for authorization of medical treatment for reasons of medical necessity to cure and relieve.

A. Peer Clinical Reviews are only performed by individuals who:

(1) Are licensed physicians qualified, as determined by the medical director or clinical director, to render a clinical opinion about the medical condition, procedures, and treatment under review;

(2) Hold a current and valid license to practice medicine in the State of California in the same license category as the ordering provider; and

(3) Meet all applicable State Utilization Review requirements.

B. Health Professionals conducting Peer Clinical Reviews will be available, by telephone, or in person, to discuss review determinations with attending physicians or other ordering providers.

4. UR process timeframes are inclusive of the entire UR process from receipt of the request for a UR decision to the issuance of the decision. Issuance of review determinations are made in accordance with the following timeframes:

A. For Prospective Review, PCHSG will issue a determination:

(1) Within 24 hours of the request for a utilization management determination, if it is a case involving urgent care, or

(2) Within 5 working days of the request for a utilization management determination, if it is a non-urgent case. However, if appropriate information which is necessary to render a decision is not provided with the original request, such information may be requested to make the proper determination, but in no event shall the determination be made more than fourteen (14) days from the date of the original request by the provider. If the Utilization Review Determination is a denial based upon the lack of receipt of the requested appropriate information within fourteen (14) days to make the proper determination, upon receipt of such reasonable information all requests will be reconsidered and the normal time frames for a Prospective Review shall be applied.

(3) Within 72 hours for an expedited review after the receipt of the written information reasonably necessary to make the determination.

B. For Concurrent Review, defined as utilization review conducted during an inpatient stay, PCHSG will issue a determination:

(1) Within 24 hours of the request for a utilization management determination, if it is a case involving urgent care; or

(2) Within 5 working days of the request for a utilization management determination, if it is a non-urgent case. However, if appropriate information which is necessary to render a decision is not provided with the original request, such information may be requested to make the proper determination, but in no event shall the determination be made more than 14 days from the date of the original request by the provider. If the Utilization Review Determination is a denial based upon the lack of receipt of the requested appropriate information within fourteen (14) days to make the proper determination, upon receipt of such reasonable information all requests will be reconsidered and the normal time frames for a Prospective Review shall be applied.

In addition, the non-physician provider of goods or services identified in

the request for authorization, and for whom contact information has been

included, shall be notified in writing of the decision modifying, delaying,

or denying a request for authorization that shall not include the rationale,

criteria or guidelines used for the decision.

(3) Within 72 hours for an expedited review after the receipt of the written information reasonably necessary to make the determination.

(4) In the case of concurrent review, medical care shall not be discontinued until the requesting physician has been notified of the decision and a care plan has been agreed upon by the requesting physician that is appropriate for the medical needs of the injured worker.

(5) In the case of Concurrent review, when treatment is denied, medical care will be continued until the Treating Physician (TP) is notified of the decision to deny, and until a care plan has been agreed upon by the TP and the care plan is appropriate for the medical needs of the injured worker. (8 CCR §9792.10(b)(1))

C. For Retrospective Review, PCHSG will issue a determination:

(1) Within 30 calendar days of the request for a utilization review determination. In addition, the non-physician provider of goods or services identified in the request for authorization, and for whom contact information has been included, shall be notified in writing of the decision modifying, delaying, or denying a request for authorization that shall not include the rationale, criteria or guidelines used for the decision.

5. Decisions to approve, modify, delay, or deny requests by physicians for authorization prior to, or concurrent with, the provision of medical treatment services to injured workers, shall be communicated to the requesting physician within 24 hours of the decision. Decisions resulting in approval, modifications, delay, or denial of all or part of the requested health care services shall be communicated to physicians initially by telephone or facsimile, and to the physician, injured worker, and if the injured worker is represented by counsel, the injured worker’s attorney, in writing within 24 hours for concurrent review, or within two business days of the decision for prospective review. In addition, the non-physician provider of goods or services identified in the request for authorization, and for whom contact information has been included, shall be notified in writing of the decision modifying, delaying, or denying a request for authorization that shall not include the rationale, criteria or guidelines used for the decision.

A. The UR Nurse will recommend certification of the proposed treatment plan that appear medically appropriate, according to medical criteria.

(1) Notification of certification decision is communicated to the requesting physician within 24 hours of the decision. (Types of notification include telephone, voicemail, facsimile or letter).

(2) Confirmation of certification for continued hospitalization or services includes the number of extended days or units of service, the next anticipated review point, the new total number of days or services approved, and the date of admission or onset of services.

B. In Non-Certification Decisions, notification is provided to the attending physician

or other ordering provider or facility rendering service through a method that will

be received within 24 hours of the non-certification decision. (Types of

notification include telephone, voice mail, facsimile or letter).

(1) Written notification of a non-certification decision is sent to the patient, attending physician if the injured worker is represented by counsel, the injured worker’s attorney, or other ordering provider or facility rendering service within 24 hours of the decision for concurrent review or within 2 business days of the decision for prospective review. In addition, the non-physician provider of goods or services identified in the request for authorization, and for whom contact information has been included, shall be notified in writing of the decision modifying, delaying, or denying a request for authorization that shall not include the rationale, criteria or guidelines used for the decision.

(2) Written notification of non-certification contains the date on which the decision was made, the name and specialty of the reviewer, or expert reviewer, the telephone number in the United States of the reviewer, or expert reviewer and hours of availability of the reviewer, expert reviewer or Medical Director shall be, at a minimum, four (4) hours per week, to be available during normal business hours, 9:00 AM and 5:30 PM, Pacific Time or an agreed upon scheduled time to discuss the decision, a clear and concise explanation of the reasons for the decision, a description of the medical criteria and the specific guidelines used, the clinical reasons for the decisions regarding medical necessity, statement that any dispute shall be resolved in accordance with Labor Code Section 4062, and details about the insurer’s appeals process, if any, and clearly state that the appeals process is on a voluntary basis as consistent with Labor Code Section 4062(a). In addition, such written notification shall include the following statements:

“If you want further information, you may contact the local state Information and Assistance office by calling (enter district I & A office telephone number closest to the injured worker) or you may receive recorded information by calling 1-800-736-7401.

and, “You may also consult an attorney of your choice. Should you decide to be represented by an attorney, you may or may not receive a larger award, but, unless you are determined to be ineligible for an award, the attorney’s fee will be deducted from any award you might receive for disability benefits. The decision to be represented by an attorney is yours to make, but it is voluntary and may not be necessary for you to receive your benefits.” and, “If you disagree with the utilization review decision and wish to dispute it, you must send written notice of your objection to the claims administrator within 20 days of receipt of the utilization review decision in accordance with Labor Code section 4062. You must meet this deadline even if you are participating in the claims administrator’s internal utilization review appeals process.”

C. When a determination is made to issue a non-certification and no peer-to- peer conversation has occurred, PCHSG will provide, within one (1) business day

of a request by the attending physician or ordering provider, the opportunity to

discuss the non-certification decision with the Clinical Peer Advisor making the

initial determination, or, with a different Clinical Peer if the original Clinical Peer

Advisor cannot be available within one (1) business day.

6. Prospective and concurrent review determinations are solely based on the information obtained by the UR Nurse or Medical Advisor at the time of the review determination; for retrospective review, the determinations are solely based on medical information available to the attending or ordering provider at the time medical care was provided. A reverse of certification can only occur when there is receipt of additional medical information that is materially different from that which was reasonably available at the time of the original determination.

7. The frequency of reviews for the extension of initial determinations is based on the severity or complexity of the patient’s condition or on necessary treatment and discharge planning activity.

8. Upon request by the public, PCHSG on behalf of the claims administrator, the claims

administrator or both shall make available the complete utilization review plan,

consisting of the policies and procedures and a description of the utilization review

process.

A. The claims administrator may make available the complete utilization review plan, consisting of the policies and procedures and a description of the utilization review process through electronic means. If a member of the public requests a hard copy of the utilization review plan, the claims administrator my charge reasonable copying and postage expenses related to disclosing the complete utilization review plan. Such charge shall not exceed $.25 per page plus actual postage costs.

All Utilization Review procedures will be in accordance with any applicable rules, regulations, guidelines or laws in the state of California.

Appeals Procedure

Any dispute regarding a non-certification/denial or modification of services decision shall be resolved in accordance with California Labor Code Section 4062. In the event of a non-certification/denial or modification of services decision, an appeal may be filed as outlined below. The appeals process is on a voluntary basis as consistent with Labor Code Section 4062 (a).

1. In the event that an attending physician, ordering provider, enrollee, injured worker, facility, patient, patient representative or other health care provider has additional medical information that may impact an initial non-certification/denial or modification recommendation, he/she may submit a written or telephonic request to PCHSG within twenty (20) days of receipt of any such determination, unless timeframes otherwise mandated by state statutes, to have the additional medical information reviewed via an Expedited or Standard Appeals Process by a Medical/clinical peer who did not make the original determination not to certify or to modify.

(a) Copies of the medical record documentation supporting the additional medical information must be included with the request for the standard appeal. UR vendor will take into account all documents, records, or other information submitted by the patient, provider, or facility rendering service relating to the case, without regard to whether such information was submitted or considered in the initial consideration of the case.

(b) Appeals consideration conducted by a Board-Certified (if applicable) clinical peer holding an active, unrestricted license to practice medicine in the State of California in the same profession, similar specialty as typically manages the medical condition, procedure or treatment as mutually deemed appropriate, AND is neither the individual who made the original non-certification decision, nor the subordinate of such an individual.

2. Appeal timeframes are inclusive of the entire appeals process from receipt of the request to issuance of a written determination. All requests for appeal are completed and issuance of the appeal decision in accordance with the following timeframes:

(a) Expedited Appeals are completed as soon as possible, and no later than 72 hours after the initiation of the appeals process;

(b) Standard Appeals are completed within 30 calendar days of the initiation of the appeal process.

(c) All appeal procedures will be in compliance with state statutes.

3. PCHSG will notify the Attending Physician or other Ordering Provider or Facility rendering service of the appeals determination through a method that will be received within 24 hours of the appeals determination (types of notification include verbal, voicemail, email, fax or letter); and issues written notification within one (1) business day of the appeals determination to the patient and Attending Physician or other ordering provider and facility rendering service (if applicable). If the patient is a child under the age of 18, the notification will go to the insured.

(a) Written notification of adverse appeals determinations includes the principal reasons for the determination to uphold the non-certification; a statement that the clinical rationale used in making the appeal decision will be provided, in writing, upon request; and in the case of expedited appeals, the method to initiate the standard appeal process.

(b) Upon request, PCHSG will provide the attending physician or other ordering

provider who has been unsuccessful in an attempt to reverse a determination

not to certify, patient, and hospital or facility rendering service, the clinical

rationale for that determination in writing.

4. The Medical Advisor, Medical Director or clinical peer will be available within 1 business day to discuss by telephone the determination with the attending physician and/or other ordering provider.

5. Records will be kept for each appeal that include:

(a) Name of the patient, provider, and/or facility rendering service;

(b) Copies of all correspondence from the patient, provider, or facility rendering service and UR Vendor regarding the appeal;

(c) Dates of appeal reviews, documentation of actions taken, and final resolution; and

(d) Minutes or transcripts of appeal proceedings (if any)

If a request to perform spinal surgery is denied, disputes will be directed to the insurance Adjuster to follow the disputed Spinal Surgery protocol in accordance with subdivision (b) of Section 4062.

Requests for Reconsideration

1. Anytime an initial determination not to certify treatment is made and no contact has occurred with the attending physician or ordering provider, the attending physician or ordering provider can request a reconsideration by the clinical peer that made the initial determination. This reconsideration process is to be used when there is disagreement of procedural notification of non-certification determinations.

A. The UR Nurse or a Medical Advisor informs the attending physician or ordering provider that within (1) business day the original Medical Advisor or designated physician (if the original is not available) will contact them.

B. The UR Nurse will inform their supervisor and Medical advisor of the attending physician or ordering provider’s reconsideration request.

C. The UR Nurse will maintain documentation of the attending physician or ordering provider’s reconsideration request, including date and time.

D. The Medical Advisor or Medical Director will be notified and given all case information.

E. If the Medical Advisor or Medical Director and the attending physician/ordering provider are not in agreement, the attending physician/ordering provider will be notified immediately of their right to initiate an expedited or standard appeal.

F. All results of the reconsideration will be maintained by PCHSG.

G. The attending physician/provider, facility, claimant and/or patient can request the disclosure of information.

H. The attending physician/provider, facility, claimant and/or patient can request the disclosure of criteria used to render non-certification.

I. The name of the criteria, edition and diagnosis of the criteria will be supplied in writing upon request within 1 business day.

J. Only a UR Nurse or Medical Advisor or Medical Director can release this information.

K. The disclosure of criteria used to render non-certification will be in compliance with the laws of California.

Utilization Review Miscellaneous Policies and Procedures

PCHSG will maintain an 800 toll free number that the review staff can be accessed from between 9:00 AM to 5:30 PM Pacific Time of each standard business day (Monday – Friday) in the provider’s local time zone.

1. The Medical Director shall bear the responsibility of oversight of the Utilization Review Program and all processes including compliance with all California Regulations detailed in Title 8, California Code of Regulations, Sections 9792.6 et seq.

2. The Medical Director shall be responsible for all Utilization Review decisions and determinations made by Physician Advisors and Medical Advisors utilized to perform the initial Utilization Review Determinations, Reconsideration Determinations and Appeal determinations. The Medical Director shall routinely audit a minimum of 1 of every 25 determinations, or an amount equal to any regulatory requirements should they be enacted, on a random basis and/or upon request of claims administrator.

3. Requests for Utilization Reviews made be made via mail to claims administrator or:

PrimeCare Health Services Group, Inc.

23372 Madero Road, Suite B

Mission Viejo, CA 92691

OR

Requests for Utilization Reviews may be made via fax to claims administrator or:

PrimeCare Health Services Group, Inc.

(888) 777-5582

Telephone access will be made available by claims administrator, from 9:00 AM to 5:30 PM Pacific time on normal business days. For requests made at times other than these, claims administrator and PrimeCare Health Services Group, Inc. shall maintain a voice mail system to handle all incoming requests and/or messages.

4. All outgoing communications related to utilization management will be conducted during providers’ reasonable and normal business hours, unless otherwise mutually agreed.

5. The review staff will identify themselves when calling by name, title and name of organization when contacting attending physician/provider, enrollee/patient/injured worker, facility, claims payor or patient representative.

6. There will be access to the 800 line after hours with the capability to leave a message on a recorder.

7. If PCHSG is closed due to unforeseen emergencies, such as inclement weather or catastrophes, a detailed message will be left on the recorder, providing the caller with applicable directions for medical care or treatment or methods to obtain authorization for care.

8. All calls that are received during business hours from providers and patients/injured workers will be returned within one-business day.

9. Upon request, utilization review staff member(s) orally inform patients, injured workers, designated facility personnel, the attending physician, and other ordering providers of specific utilization review requirements; and patient, injured workers, hospitals, physicians, and other health professionals of PCHSG review procedures.

Confidentiality Procedures

All patient information obtained during the utilization review process is considered part of the PCHSG business record. All medical information is subject to state and federal regulations protecting confidentiality of medical information, and is subject to release only within strict guidelines of confidentiality. Medical information is released only within the requirements of such regulations and in accordance with strict corporate guidelines. Listed below are the procedures in place to protect the confidentiality of the patient’s medical information.

1. Employees are required to review our confidentiality and non-disclosure agreement upon employment. This agreement is to be signed by the new employee and yearly thereafter, and is kept in the employee’s personnel file.
2. Upon request, there is a patient confidentiality of medical information form that is forwarded to the patient describing how the medical information will be kept confidential while utilization review is being completed.
3. Detailed patient-identified information is released only with the patient’s authorization or, where applicable, state laws, rules and regulations provide authorization. This includes all communications and records transmitted or stored, including cellular phones, fax or electronic systems.
4. All medical information will be maintained in a secure environment, which has a sophisticated security system. Only authorized personnel can access the system with appropriate password codes.
5. Each state and federal statute regarding confidentiality and non-disclosure is adhered to and updated when applicable.
6. Provider specific data obtained during the review process is not publicly released. It can be shared only with those agencies (i.e., claims administrators) that have the legal and contractual authority to receive such information. This includes all communications and records transmitted or stored, including cellular phones, fax or electronic systems.

A. Special care is taken when faxing information that includes patient specific medical and identifying information. All fax correspondence cover pages will contain a confidentiality clause statement.

B. All email transmissions will contain a confidentiality clause statement. Utilization Review Letters and Activity Notes may only be emailed to authorized parties.

7. Medical Information collected is used solely for the purpose of utilization review, quality assurance, discharge planning and catastrophic case management.
8. UR patient information includes any information captured within the utilization review process such as demographics, medical treatment requests/approvals, provider and case activities/results. Worker specific information includes injury cause, job type and any return-to-work information. Provider specific information is any clinical, treatment outcomes or provider specific information capture through the utilization process for a specific patient
9. Review notifications containing information that might suggest a diagnosis such as non-certification rationale, are sent only to the patient, physician, facility or other health care provider. Review notifications to employers do not contain medical information.

Statement Of Regulatory Compliance

As noted, this Utilization Review plan has been developed in accordance with Labor Code Section 4610, 4604.5 and any or all other duly enacted Labor Code Sections, or DWC regulation that may apply currently. If any changes to the Labor Code, Department of Workers’ Compensation Administrative Rules or current regulations that govern any part of this Utilization Review plan are enacted, they are hereby incorporated herein and take precedence over any provision of this Utilization Review plan that is in conflict with these enacted regulations. If during the course of time any term, provision, covenant or condition of this Utilization Review plan is held by a court of competent jurisdiction to be invalid, void or unenforceable, the remainder of the provisions herein shall remain in full force and effect and shall in no way be affected, impaired or invalidated as a result of such decision.

SECTION 4

MEDICAL DIRECTOR

MEDICAL STAFF

MEDICAL DIRECTOR:

Lester L. Sacks, MD

California License # A28341

New York License # CERT6355598