||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, without the
employer or its insurance carrier obtaining legal representation, or incurring the costs associated with legal
involvement in the utilization review process.
||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.
||At this time, Utilization Review is limited to health care
recommendations subject to practice guidelines developed by the HCAP.
||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)
||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
||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.
||In the instance of a compensable claim where the treatment is outside the applicable Practice Guideline for
which the health care provider requests pre-authorization but the employer/carrier advises that it does not
pre-authorize treatment, such response should be interpreted as tantamount to a denial of such treatment
so that the claimant may file a Petition with the IAB to determine whether the treatment is compensable.
||In the instance of a compensable claim in which open surgery is recommended by the health care provider
and stated by him/her to be within the applicable Practice Guideline, the following procedure may be followed by the operating surgeon to facilitate resolution of payment for such treatment: The operating surgeon must specify the
particular surgery to be performed and must certify in writing that: (a) the surgery is causally related to the
work accident, and (b) the surgery is within the Practice Guideline, with specific reference to the Practice
Guideline provision relied upon.
||The information set forth above must be set forth by the operating surgeon in a separate written
report, not through a copy of office notes and/or records. The employer/carrier must within 30
days from receipt of the above either accept/pre-authorize or deny such treatment. If the
treatment is denied as non-compliant with the Practice Guidelines, it must be referred to Utilization
Review within 15 days of date of denial in accordance with §2322F(h)(j). If the treatment is denied
as not causally related to the compensable work accident, the claimant may file a Petition with the
Industrial Accident Board to determine whether the treatment is compensable. If the employer/
carrier neither accepts/pre-authorizes nor denies the treatment within the 30-day period
referenced above, then the treatment will be deemed compensable if performed.
||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 by the company performing the review, for emergency care, but no later than 15 calendar days from receipt of the
aforementioned information by the company performing the review.
||If a party disagrees with the findings following utilization
review, a petition may be filed with the Industrial Accident Board for de novo
review. 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
claimant’s attorney of record, the health care provider in question,
and the employer or its insurance carrier.
||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.