Examples of "bad" UR decisions are critical to prove to the Division of Workers' Compensation (DWC) that the Utilization Review (UR) process needs to change.  While there are UR physicians doing a good job with the very limited information that they are given, there are some reviewers who are totally unreasonable and unqualified to review surgical requests.This feedback form is to identify the bad players and to help DWC focus their audit efforts on those entities and to help identify changes that will improve the process. Complete the below feedback form and attach a redacted copy of the UR decision to provide us with your input.  You can send in as many examples as you have. 

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* 1. Attach redacted UR Decision.

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.
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* 2. Name of Workers' Compensation Carrier/Self-Insured Employer.

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* 3. Request for Authorization (RFA) for medical treatment was sent to:

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* 4. If sent to the claims adjuster, enter the name of the claims adjuster and the date RFA was sent:

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* 5. If RFA was sent to Utilization Review Company, enter name of UR Company.

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* 6. Name of Physician Reviewer/Specialty

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* 7. Date Denial/Modified RFA notice was received:

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* 8. Utilization Reviewer Denied the following:

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* 9. Utilization Reviewer Inappropriately Modified the request:

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* 10. Did the Utilization Reviewer request additional information?

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* 11. Could the requested information have been found in:

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* 12. In your own words, summarize the circumstances of the case.

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* 13. Did you appeal the Utilization Review decision?

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* 14. If yes, did you have a peer-to-peer review with an orthopaedic surgeon?

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* 15. If no, what was the specialty of the reviewer?

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* 16. Did you help the injured worker file an Independent Medical Review (IMR)?

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* 17. If yes, did Maximus:

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* 18. Demographic information (will be kept confidential):

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