Key takeaways
Utilization review is a medical-authorization process; the important documents are the treatment request, review decision, and appeal instructions.
Records to put together
- Treatment request
- Utilization-review decision
- Medical records cited
- Official appeal/review instructions
Questions to verify
- What medical rationale is stated?
- Was required information missing?
- Can the provider supplement the request?
- What deadline controls review?
Important caution
Utilization-review procedures are highly state-specific.
When a lawyer consultation may help
- A deadline, hearing, denial, or benefit change is close or disputed.
- The medical evidence and the insurer/employer position conflict.
- Permanent restrictions, settlement, third-party liability, employment status, or retaliation may affect the file.