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How Will a Utilization Review Affect My Case?


When you make a workers’ compensation claim, you can generally expect the insurer will cover all of your medical care related to your injury or illness. According to the Pennsylvania Department of Labor and Industry, your insurer may request a utilization review of your medical care.

This review will look into the medical care you have received to determine if it is necessary.

Your rights

You should receive a notice that the insurer has asked for a utilization review. You have the right to issue a statement about your medical care and why you feel it is necessary. You also should follow any instructions the paperwork gives you. If you disagree with the findings of the review, you also have the right to petition.

The impact

A utilization review could mean a finding that the treatment you got was not necessary to treat your condition. During the review process, the bills relating to the treatment in question are on hold, meaning they will not receive payment until the issuing of the final decision.

There is the potential the review will result in the insurer not having to pay the bills, but do understand the law prevents the provider from billing you directly for the unpaid bills. However, you may be unable to get prescriptions if they are part of the treatment under review until the review is complete.

A utilization review may put some things on hold until the final determination. The insurer makes the request for this process and pays for it if the insurer feels there is something questionable about the treatment you receive. You do not pay for it or have to do anything during the process.