Were you injured on the job in Fresno? If so, it is absolutely crucial that you get all of the medical treatment that you need—for emergency treatment to rehabilitative care. The California Department of Industrial Relations (DIR) explains the law clearly: an injured worker is “entitled to reasonable medical treatment to cure or relieve work-related injuries and illnesses.”
Of course, getting the full and proper care that you need is not always so straightforward. Employers and insurers may sometimes try to deny coverage for care on the grounds that it is “not necessary” or “not related.” This is where utilization review (UR) could come into play. Here, our Fresno workers’ compensation lawyer explains utilization reviews (URs) in California.
As described by the California DIR, a utilization review is simply “the process used by employers or claims administrators to review treatment to determine if it is medically necessary.” Employers and claims administrators must put a UR system in place for handling workers’ comp cases. In applying utilization review, employers/insurers must comply with the legal requirements of CA Labor Code § 4610. The statute clearly states that workers’ compensation insurance must cover all services that are “medically necessary to cure and relieve” the claimant’s injury or illness.
Under California state law, there is a specialized process in place that helps to ensure that injured workers get the immediate medical care that they need without being subject to a long, drawn-out dispute through a UR process. Specifically, state regulations require the pre-authorization of up to $10,000 in medical treatment. Care must be pre-authorized within the first 24 hours of the submission of a workers’ compensation claim.
You have the right to appeal the denial of any workers’ compensation benefits, including the coverage of medical treatment. If medical coverage is denied during utilization review, it typically means that the reviewer has determined that the care/treatment in question is not “medically necessary.” An injured worker has the right to appeal such as denial. This type of workers’ comp appeal is generally referred to as an independent medical review (IMR). An experienced Fresno, CA workers’ comp lawyer can help you prepare a compelling, well-supported appeal that establishes that the medical treatment that you are seeking is reasonable and necessary.
Joseph C. Yrulegui is an experienced workers’ compensation lawyer. If you are an injured worker with questions about medical treatment, we are here as a legal resource. Contact our legal team today for a strictly confidential case evaluation. From our Fresno law office, we help injured workers navigate the claims process throughout the San Joaquin Valley.