A utilization review can delay payment for disputed medical treatment in a Pennsylvania workers’ compensation claim and determine whether that treatment is reasonable or necessary for the work injury. The review does not decide every part of your claim. It focuses on the treatment being challenged, which can affect payment, access to care, and the next steps needed to keep your medical treatment moving.
Luxenberg Garbett Kelly & George P.C. assists injured workers across Western Pennsylvania when medical treatment becomes delayed, disputed, or denied during a workers’ compensation case. Our New Castle workers’ compensation attorneys can review the determination, evaluate the medical issues, and explain your options for challenging the result.
This guide explains what a utilization review is, who can request one, how the process works, how it affects your medical care and benefits, and what to do if treatment is denied. Call Luxenberg Garbett Kelly & George P.C. at (724) 658-8535 for a free consultation.
What Is a Utilization Review in Pennsylvania?
A utilization review is the process used to evaluate whether medical treatment for a work injury is reasonable and necessary. In Pennsylvania, this process is authorized by Section 306(f.1)(6) of the Pennsylvania Workers’ Compensation Act, which provides for an impartial review of the necessity of treatment rendered to, or proposed for, a work-related injury or illness.
The Health Care Services Review Division administers the utilization-review process under Chapter 127 of the Medical Cost Containment Regulations. The reviewer asks whether the identified provider’s past or proposed treatment is reasonable and necessary for the work injury; the result can affect payment for that treatment or lead to a petition before a workers’ compensation judge. That medical-treatment question is narrower than whether the worker and injury satisfy Pennsylvania workers’ compensation eligibility rules, so an unfavorable UR determination should not be described as deciding the entire claim.
Who Can Request a Utilization Review in Pennsylvania?
A utilization review may be requested by or on behalf of the employer, the insurer, or the employee. While these parties can initiate the process, health care providers are not permitted to file UR requests. The review focuses strictly on the provider and treatment identified in the request, which may include care that was provided, ordered, referred, or prescribed.
Pennsylvania also enforces strict limits on when some requests can move forward. For example, an employer or insurer seeking a retrospective review must file within 30 days after receiving both the bill and the medical report for the disputed treatment. All requests must be filed online through the Workers’ Compensation Automation and Integration System (WCAIS).
The employer or insurer pays the reasonable and customary URO charge, even when the employee requested the review. You are not responsible for the cost of the review as the injured worker.
Workers’ Compensation Attorney in New Castle, Luxenberg Garbett Kelly & George P.C.
Lawrence M. Kelly, Esq.
Lawrence M. Kelly represents injured workers in New Castle, Lawrence County, and throughout Western Pennsylvania. Admitted to practice in Pennsylvania since 1983, he focuses his practice on workers’ compensation and personal injury litigation.
Mr. Kelly earned his Juris Doctor, cum laude, from the University of Akron School of Law. A Board Certified Civil Trial Specialist through the National Board of Trial Advocacy, he holds an AV Preeminent rating from Martindale-Hubbell and has been selected to the Pennsylvania Super Lawyers list for multiple years.
Joseph A. George, Esq.
Joseph A. George represents injured people in workers’ compensation and personal injury matters in New Castle and the surrounding region. His practice includes workers’ compensation, personal injury, medical malpractice, and motor vehicle accident cases.
Mr. George earned his Juris Doctor from Duquesne University School of Law and has been admitted to practice in Pennsylvania since 1996 and in Ohio since 1997. He has been selected to the Pennsylvania Super Lawyers list from 2018 to 2026 and holds an AV Preeminent rating from Martindale-Hubbell.
What Are the Types of Utilization Reviews?
Pennsylvania allows three types of utilization reviews. The timing of the review depends on where the disputed treatment stands in the care process:
| Type of Review | When It Occurs | Purpose |
|---|---|---|
| Prospective Review | Before the medical service is provided | To evaluate proposed treatment before it begins |
| Concurrent Review | During the delivery of medical care | To check if ongoing care remains necessary and appropriate |
| Retrospective Review | After the medical service has been provided | To evaluate past treatment after services were provided |
What Happens During the Utilization Review Process?
Once a request is filed in WCAIS, the Bureau of Workers’ Compensation assigns it to a Utilization Review Organization (URO) authorized by the Secretary to perform reviews for Pennsylvania workers’ compensation. The URO begins the record review process and assigns the file to a reviewer.
Under Chapter 127 of the Medical Cost Containment Regulations, the assigned reviewer must be licensed in the same profession and specialty as the provider under review. A UR request is complete when the URO receives the medical records or 35 days from the notice of assignment pass, whichever happens first. Once the request is complete, the URO must finish its review and render a determination within 30 days.
When a utilization-review notice arrives, verify the provider, treatment, and time period being challenged rather than assuming all care is under review. The provider under review and other treating providers should supply records that show the diagnosis, treatment plan, objective or clinical findings, changes in symptoms, and response to care. If the disputed treatment involves counseling, psychiatric medication, or another mental-health service, the record should also explain how that care relates to the accepted work injury or the asserted work-related mental-health condition.
Key Takeaway: The URO’s 30-day deadline starts after the UR request is complete. The reviewer must match the provider’s profession and specialty.
How Does a Utilization Review Affect Your Medical Care?
A utilization review may conclude that a particular treatment does not meet Pennsylvania’s reasonableness-and-necessity standard for the accepted work condition, and the insurer may suspend payment for that disputed treatment while the review proceeds. The URO does not decide every causation issue in the claim. If the insurer separately argues that symptoms come only from a pre-existing condition rather than a work-related aggravation, that defense requires its own medical and factual response instead of being folded into the treatment-review question.
If the URO rules against the treatment, the insurer may not have to pay for the care being challenged unless the determination is later changed through a petition for review. Pennsylvania law bars a provider from holding an employee liable for costs related to care or services connected with a compensable work injury under the Act. Payment disputes can still affect access to prescriptions, follow-up care, or other treatment while the UR process is pending.
What Happens If a Utilization Review Denies Treatment?
If the utilization review denies the disputed treatment, you have the right to challenge the decision by filing a Petition for Review of a Utilization Review Determination. The petition is heard and decided by a workers’ compensation judge, not by the URO or the insurer.
At the hearing, both sides may submit additional medical evidence, and the judge weighs the UR Determination Report against that evidence to decide whether the treatment was reasonable and necessary. A petition for review must be filed within 30 days after receipt of the URO’s determination, so reviewing the report promptly matters for injured workers in Lawrence County and across Pennsylvania.
Luxenberg Garbett Kelly & George P.C. can prepare the petition, organize medical evidence, and present your position before the workers’ compensation judge.
How Will a Utilization Review Affect My Case Overall?
A utilization review can affect the pace of care and the direction of a claim, but it does not calculate or directly decide wage-loss benefits. Keep a separate record of days missed, written work restrictions, post-injury earnings, and each benefit check so a treatment dispute does not obscure a payment problem. The weekly workers’ compensation payment is based on wage and disability rules, even though delayed or denied treatment can still affect recovery, return-to-work planning, and case deadlines.
Talk to a New Castle Workers’ Compensation Attorney Today
If a utilization review is delaying or denying treatment in your workers’ compensation claim, the next step depends on the URO determination, the treatment being challenged, and the deadline to respond. Luxenberg Garbett Kelly & George P.C. can review what was denied, help identify the medical support needed for your position, and help you respond before the applicable deadline.
Our workers’ compensation attorneys assist injured workers in New Castle, Lawrence County, and across Western Pennsylvania with disputed medical treatment and claim issues related to utilization review.
Call (724) 658-8535 to schedule a consultation. Our office is located at 315 N Mercer St, New Castle, PA 16101, and we serve clients across Pennsylvania, including Allegheny County.
Frequently Asked Questions
Who pays for a utilization review in Pennsylvania?
The injured worker does not pay for the review. Instead, the employer or the insurer covers the URO fee.
Can I be billed for treatment denied by a utilization review?
A provider cannot make you personally responsible for covered care tied to a compensable work injury under the Act. The payment issue remains part of the workers’ compensation claim.
How long does a utilization review take in Pennsylvania?
The timing depends on when the UR request becomes complete. Completion happens when the URO receives the medical records or 35 days pass from the notice of assignment, whichever comes first. The URO then has 30 days to issue its determination.
Who can request a utilization review?
The employer, insurer, or employee may request a UR. Health care providers cannot start the process, and requests must be filed through WCAIS.
Can I challenge a utilization review determination?
You can challenge the outcome by filing a Petition for Review of a Utilization Review Determination. A workers’ compensation judge can hear the petition and consider further medical evidence before making a decision.
Will a utilization review stop my workers’ compensation benefits?
A UR does not directly decide wage loss benefits. It focuses on the medical treatment being challenged, and payment for the disputed treatment or portion of treatment may be suspended during the review.
