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What are qualified medical evaluators and utilization reviews?

On Behalf of | Nov 20, 2018 | Firm News |

When a person submits an application for workers’ compensation, they might have to go through a process in order to receive benefits. This is to ensure that the worker qualifies for benefits.

The application process can include several components, some of which might seem complicated. It is imperative that all workers who are trying to get workers’ compensation understand some important facts about the process of applying.

What is a qualified medical evaluator’s purpose?

A qualified medical evaluator is a person who provides information that can be used to determine whether you are disabled. They write up reports that are used for medical-legal purposes. Not all qualified medical evaluators are medical doctors. Some are chiropractors, optometrists, psychologists, podiatrists, osteopathy doctors, acupuncturists and dentists.

You will have an examination with one of these professionals. They will review the information related to your claim before making their report. They all must take an examination to ensure they are qualified to do this job. They also must take continuing education courses.

What is a utilization review?

The utilization review (UR) is how the medical necessity of treatments are determined in workers’ compensation cases. In California, there are medical treatment guidelines that are used to assess the medical necessity of treatments that are recommended. All claims administrators or employers must complete the UR process, which must be handled in accordance with Labor Code Section 4610.

Since the UR process is governed by California laws, it must be followed precisely. No applicant can try to skirt around these guidelines. It is possible that the UR companies and administrators can face penalties if they don’t comply with the regulations.

What can I do if I don’t get the benefits I’m due?

Once you go through the process, you will find out what benefits you are going to receive. When you get this document, read through it carefully. There are times when the approval might not be what you should be due. If this happens, you must act quickly since there are strict timelines for appealing a workers’ compensation ruling. Understanding your rights for appealing and the process can help you in these cases.