09% Please ?ll out this form as completely as possible. This information will remain con?dential, est: pt to the extent necessary to

run

  
 
    

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i Utilization Review (UR) Complaint Form
007/0 State of California

Division of Workers? Compensation Medical Unit

 


JUL 15 2013 

  
 

investigate the complaint. ?information is not knots-n. leave item blank.

  
 

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. URI-computer it.



ale Code 

     
 

Name of person
making complaint:

I odd} '5 date; ?25-



 

Person mailing, enl'nplainl {check one):
injured [j Attorney El Provider ()ther:

 

ab .316 if)

Date of iniuri lClaim nurnher

 

I?ll?Lille? t} EU. Eli. 

Nature of complaint teheel; all thal apply}: If you had trouble contacting the UR reviewer {check all that
apply):
ii Decision to modify. delay, or den} treatment was made by El Modi?cation. delay or denial letter did not contain
1: non-physician the reviewers contact information
Inadequate explanation ofthe reasons for UR decision Failure to specify in MDD letter a four hour time block

when reviewer available
Medical criteria or guidelines used to make decision

were not disclosed CI Unable to reach reviewer to discuss treatment decisions

3 decisions were not made within required time limits [3 Failure to maintain telephone access for UR authorization
from 0 am. to 5:30 pm. PST on normal business days
a Treatment denied 501er because the condition was not
addressed by the ACUEM Practice Guidelines. El Unable to leave a message after business hours

I: .

Lu..i

\io statement in decision that dispute shall be resolved in l:l UR reviewer calls you after CA business hours
accordance with LaLmr ("ode section 4062

5-3.2} inc-til denied es. en though service was authorizecl

iet'nrestet'i nEl vie-es denied for loci; of interniatimi. but
.iie din not request additional information

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Please provitt brie-[description nfthe complaint and attach all supporting documentation.

it' necessary: add extra pages for description: . 

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I subnilt tins complaint to the DWC Medical lnut, either:

I. Print this form and mail or fax it to: DWC Medical Unit-UR. PO Box ILiakland, CA users?nan; UR

i?mt?tplaints. Fast: (Elli) 236*0b36

2. Save the completed form to your computer and e-mail it to: ?Q?l?anaged?ag?gtirears-oi-. Please put complaint? in the
stinieet line.

 

 

However you submit this form, he sure to keep a copy for your records.

isn?t: UR complaint form 



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