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5.1 |
Pursuant to chapter 101, title 29 of the Delaware Code,
the Department of Labor has developed a utilization review program with the
intent of providing reference for employers, insurance carriers, and health
care providers for evaluation of health care and charges. The intended purpose
of utilization review services is to provide prompt resolution of issues
related to treatment and/or compliance with the health care payment system or
practice guidelines for those claims which have been acknowledged to be
compensable. |
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5.2 |
An employer or insurance carrier may engage in utilization review
to evaluate the quality, reasonableness and/or necessity of proposed or
provided health care services for acknowledged compensable claims. Any person
conducting a utilization review program for workers’ compensation shall be
required to contract with the Office of Workers’ Compensation once every two
(2) years and certify compliance with Workers’ Compensation Utilization
Management Standards or Health Utilization Management Standards of Utilization
Review Accreditation Council (“URAC”) sufficient to achieve URAC accreditation
or submit evidence of accreditation by URAC. |
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5.3 |
At this time, Utilization Review is limited to health care
recommendations subject to practice guidelines developed by the HCAP. |
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5.4 |
An employer or insurance carrier may request utilization review by
complying with all the terms and conditions set forth on the forms attached
hereto. Upon completion and submission of the forms, information package and
medical records package by the employer or insurance carrier, the designated
utilization review company will review treatment to determine if it is in
compliance with the practice guidelines developed by the Health Care Advisory
Panel and adopted and implemented by the Department of Labor. (See Appendix A)
All past, prospective and concurrent health care decisions must be reviewed and
a Utilization Review determination made no later than three (3) working days
from receipt of the aforementioned information, for emergency care, but no
later than 15 calendar days from the date of the treatment recommended by the
physician or less if set forth in URAC guidelines. |
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5.4.1 |
The utilization review company shall be randomly selected by the Department of Labor. The
utilization review company first assigned to the case will remain with that case throughout its
duration. The Department of Labor will collect all documentation required to be submitted
pursuant to the utilization review process and send such documentation for review to the utilization
review company.
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5.4.2 |
If the claim is denied by an employer or insurance carrier for non-compliance with any applicable
Practice Guideline, only the first bill for such treatment, and not all subsequent bills for the same
service, need be denied and referred to utilization review.
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5.4.3 |
All past, prospective and concurrent health care decisions must be reviewed and a Utilization
Review determination made no later than three (3) working days from receipt of the
aforementioned information, for emergency care, but no later than 15 calendar days from the date
of the treatment recommended by the physician or less if set forth in URAC guidelines.
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5.5 |
If a party disagrees with the findings following utilization
review, a petition may be filed with the Industrial Accident Board for de novo
review. |
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5.5.1 |
The decision of the utilization review company shall be forwarded by the Department of Labor, by
Certified Mail, Return Receipt Requested, to the claimant, the health care provider in question,
and the employer or its insurance carrier. A decision of the utilization review company shall be
final and conclusive between the parties unless within 45 days from the date of receipt of the
utilization review decision any interested party files a petition with the Industrial Accident Board for
de novo review.
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5.6 |
If there are no current practice guidelines applicable to the
health care provided, a party may file a petition with the Industrial Accident
Board seeking a determination of the appropriateness of treatment. |
