Utilization Reviews – A Multi-Perspective of Employers’ Burden and Guide to UR Process
Garrett W. Brindle, Esquire
The Utilization Review Process Section 306 of the WC Act provides that disputes as to reasonableness and necessity are to be resolved via the Utilization Review (UR) Process set forth in that provision of the statute. There is no other way to contest the reasonableness and necessity of treatment in a PA WC claim. Some other jurisdictions permit a carrier’s internal utilization management determinations to be used for approval or denial of care, but those are primarily jurisdictions where the WC carrier has medical control. In PA, there is no such carrier control and, in any event, the statute specifically states that the UR process must be utilized. Any denial of care for lack of reasonableness and necessity without a favorable UR can lead to imposition of penalties.