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Utilization Review Complaint Form

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State of California

Division of Workers’ Compensation Medical Unit

Utilization review complaint form

What it is and how to use it

In California, all employers or insurance companies handling workers’ compensation claims are

required to have a utilization review (UR) program. A UR program allows an employer or insurance

company to review a treatment request made by an injured worker’s physician to determine if the

treatment is medically necessary. Following this review, the treatment request can be approved, denied,

or modified. The UR process is governed by Labor Code section 4610 and implemented through

regulations beginning at California Code of Regulations, title 8, section 9792.6.

Medical providers, injured workers or others who find that UR has not been performed as it is required

by statute or regulations can file a complaint with the DWC. The attached form may be used to register

a complaint regarding UR services connected with workers’ compensation injuries and treatment.

All valid complaints will be used to assist DWC during our utilization review organizations (URO)

investigations in oversight of the UR organizations and programs.

Injured workers may also benefit from reading the UR fact sheet (A) at

Please fill out the form as completely as possible, checking all complaint boxes that apply. Please

include any additional information or documentation required to clarify the details of your complaint,

including the accepted request for treatment (RFA) form with a copy of the appropriate (applicable)

medical report, and corresponding URO decision letters.

Completed complaint forms can be sent by U.S. mail, fax or e-mail to the address provided at the

bottom of the form.

Glossary of terms:

All written material related to the complaint(s), including the request for

Supporting

documentation:

treatment (RFA form), the relevant treating physician’s medical report, and

the corresponding URO decision letters or faxes regarding modification, delay

or denial of specific treatment request(s).

“Medical Treatment Utilization Schedule” means the set of treatment

MTUS:

guidelines adopted by the Administrative Director pursuant to Labor Code

section 5307.27 and set forth in Article 5.5.2 of this Subchapter, beginning

with section 9792.20. The state of California now uses the MTUS as its

medical treatment guidelines to assist in appropriate UR decision making.

“Utilization Review Organization” or “UR Company” means the agency or

URO:

company that provides utilization review (UR) services for employers, claims

administrators, or insurers. UR services are used to determine the medical

necessity of proposed medical treatments for injured workers.

DWC UR complaint form 4/14

Utilization Review Complaint Form

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