Have you suffered an injury while on the job in California? Perhaps you “threw your back out,” twisted your ankle or worse. If so, you may become familiar with part of the claims process of receiving medical benefits called “utilization review.” For each personal injury case there is a claims administrator assigned to it. The claims administrator uses utilization review, or UR, which is a program designed to ensure that your medical treatment is consistent with California guidelines for every type of injury. Furthermore, the UR can decide that doctor-recommended treatment will not be approved for a particular kind of injury.

Sometimes there is a dispute as to what constitutes the medical treatment that best adheres to the California guidelines and/or what is best for the injured worker’s recovery. As of 2013, the way these disputes were handled changed. From that point forward, an entity called the Independent Medical Review, or IMR, resolved all such disputes. In other words, if your claim is denied, you might still be entitled to medical benefits if the IMR decides the initial evaluation of the claims administrator was incorrect. If you would like to listen to a 35-minute podcast informing you about the roles of the UR and IMR, you can do so here: IMR podcast.

1. Who approves treatment recommended by the doctor?

The claims administrator or another person handling the claim can approve the doctor-recommended treatment. Only a physician who has a thorough understanding of your particular injury can change or deny the treatment that is being recommended. In a dispute, the IMR will resolve it with one or more of their appointed physicians. A new physical examination will not be necessary, generally speaking. The IMR physician will evaluate your case based on your existing medical records.

2. How soon can I get treatment?

The claims administrator has five days from the time your doctor has requested your treatment to do the review and make a conclusion. In some more complicated cases, the claims administrator is allotted up to 14 days to do the review and make a decision.

3. What if more than two weeks have passed?

If more than two weeks have passed since the doctor sent his or her recommendation for medical treatment to the claims administrator, you can file a form called a “declaration of readiness” to help speed up the process so you can get your required medical care.

4. If I appeal to the IMR, how long will it take for them to decide?

It usually takes about 40 days for the IMR to complete their assessment of a case.

If you have been injured on the job in California, you may be entitled to significant medical benefits. Hiring an experienced attorney can be an excellent way to secure these benefits and put you on the path to recovery.