Proposed Utilization Review Amendments to California Workers' Compensation: What to Know

The California Division of Workers' Compensation (DWC) has proposed amendments to regulations relating to utilization review standards and related processes. These changes affect sections 8 CCR §§9767.6 through 9792.27.17.

Key updates include:

1. Medical Treatment Utilization Schedule (MTUS):
   • Proposed amendments to 8 CCR § 9792.24.2 and adoption of 8 CCR § 9792.24.8, regarding proposed evidence-based update and adoption to the Medical Treatment Utilization Schedule.
   • Adopts and incorporates by reference the Chronic Pain Guideline (ACOEM 12/19/2024) into the MTUS from the ACOEM Practice Guidelines for the treatment and evaluation of patients who have chronic pain; and
   • Adopts and incorporates by reference the Cannabis Guideline (ACOEM 01/28/2025) into the MTUS from the ACOEM Practice Guidelines for the treatment of pain.
2. Medical Provider Networks (MPNs):
   • Adds a provision that requires the insurer or employer to deliver to the initial primary treating MPN physician selected by the employee, within 20 days of notice of selected physician, all relevant medical records relating to the claim, if any, including the results of diagnostic and laboratory testing done in relation to the injured employee's treatment.
   • Adds a provision that requires the insurer or employer to advise any subsequently selected MPN physician that any medical record or diagnostic and laboratory test result deemed relevant by that provider will be delivered upon request.
   • Adds a provision that requires the insurer or employer to also advise all selected MPN physicians of the relevant MPN identification number, name, telephone number, fax number, email address, and mailing address of the person or entity to whom a request for authorization and bills should be sent.
   • Clarifies that a Petition for Change of PrimaryTreating Physician cannot be utilized to seek a change of physician for a covered employee who is treating with a physician within the MPN, except as allowed under §9786, subd. (b)(6), which states that a clear showing that the primary treating physician, providing medical treatment to the employee within the first 30 days following the date of injury, has a pattern and practice of failing to render treatment that is consistent with the MTUS.
3. Utilization Review (UR) Processes:
   • Clarified definitions, including "business day" as equivalent to "working day" or "normal business day"
   • New provisions for electronic submissions of UR plans and use of electronic signatures
   • UR plan material modifications must now be submitted using DWC Form UR-01
   • Revised timelines for UR decisions, including changes to information request deadlines
   • Added requirement to identify "30-day exemption" treatments in written approvals
4. Utilization Review — MTUS Drug Formulary
   • Amends text to state that information must be requested within no less than 4 business days, instead of two business days, from the date of receipt of the request for authorization; and
   • Amend text to state that the timeframes set forth in sections 9792.9.3 and 9792.9.6 and the requirements in sections 9792.9.4 and 9792.9.5 will apply to a request for authorization that requests both drugs and non-pharmaceutical treatment related to the same “injury or illness” instead of “condition”
5. Request for Authorization (RFA):
   • RFAs can now be sent via electronic data interchange by agreement of the parties
   • Deletes “the DWC Form RFA” and replaces with “request for authorization”.
   • Adds a provision that, upon receipt of a request for authorization that does not meet the definition of a complete request for authorization, a claims administrator, non-physician reviewer as allowed, or physician reviewer must either accept the request as a complete request for authorization and comply with the requirements or mark it "not complete" and return it to the requesting physician, specifying the reasons for the return of the request, no later than five business days from receipt.
6. Physician Reporting:
   • Form PR-1 "Treating Physician's Report" is now optional, not mandatory
   • Primary treating physician's progress reports must be on PR-2, PR-1, or as a narrative report
   • Narrative reports must include the same declaration under penalty of perjury as PR-2 or PR-1 forms
7. Independent Medical Review (IMR):
   • Updated DWC Form IMR to include a Physician Specialty field
   • Clarified rules on submission of newly developed medical records by employees
8. Administrative Penalties:
   • Clarified that non-physician reviewers are prohibited from denying or modifying (not just reviewing) treatment requests

These proposed changes aim to streamline processes, improve communication, and enhance the overall efficiency of the workers' compensation system.

The public comment period for these amendments is open until 11:59 p.m. (PT) on 03/14/2025. Written comments may be submitted by facsimile transmission (FAX), addressed to the Maureen Gray, at (510) 286-0687. Written comments may also be sent electronically (via e-mail), using the following e-mail address: dwcrules@dir.ca.gov.

For a detailed review of the proposed changes, please refer to the CA DWC website.

If you have any comments or questions, please contact us here.

Additional Resource Links:

Utilization Review Regulations: DWC Utilization Review Regulations

MTUS: DWC Evidence-Based Updates to the Medical Treatment Utilization Schedule (MTU