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D.C. Municipal Regulations (Last Updated: September 13, 2017) |
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Title 7. EMPLOYMENT BENEFITS |
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Chapter 7-1. [DELETED] |
Section 7-126. UTILIZATION REVIEW
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126.1 Any medical care or service furnished or scheduled to be furnished under the Act shall be subject to utilization review. The review may be performed before, during, or after the medical care or service is provided.
126.2 A utilization review organization or individual used pursuant to the Act shall be certified by the Utilization Review Accreditation Commission.
126.3 The claimant or the Program may initiate utilization review where it appears that the necessity, character, or sufficiency of medical services is improper or clarification is needed on medical service that is scheduled to be provided.
126.4If a review of medical care or a service is initiated under this section, the utilization review organization must make a decision no later than sixty (60) days after the utilization review is requested. If the utilization review is not completed within one hundred-twenty (120) days of the request, the care or service under review shall be deemed approved.
126.5 The report of the review shall specify the medical records considered and shall set forth rational medical evidence to support each finding. The report shall be authenticated or attested to by the utilization review individual or by an officer of the utilization review organization. The report shall be provided to the employee and the Program.
126.6Any decision issued by the utilization review organization under this section shall inform the claimant of his or her right to reconsideration or appeal of the decision.
126.7 A utilization review report which conforms to the provisions of this section shall be admissible in all proceedings with respect to any claim to determine whether medical care or service was, is, or may be necessary and appropriate to the diagnosis of the claimant's injury.
126.8 If the medical care provider or claimant disagrees with the opinion of the utilization review organization or individual, the medical care provider or claimant may submit a written request to the utilization review organization or individual for reconsideration of the opinion.
126.9The request for reconsideration shall be in writing and contain reasonable medical justification, and may provide additional information if the medical care or service was denied because insufficient information was initially provided to the utilization review organization. The request for reconsideration shall be made within sixty (60) calendar days of the claimant’s actual receipt of the utilization review report if the claimant is requesting reconsideration, or within sixty (60) calendar days of the medical provider’s actual receipt of the utilization review report, if the medical care provider is requesting reconsideration.
126.10 If the utilization review organization denies the medical care provider’s or claimant’s request for reconsideration, the medical care provider or claimant may appeal the reconsideration decision by applying for a hearing before the OHA within thirty (30) days of the date of the reconsideration decision.
126.11The Superior Court of the District of Columbia may review the ALJ’s decision without an appeal to the Compensation Review Board. The decision may be affirmed, modified, reversed, or remanded at the discretion of the court. The decision shall be affirmed if supported by substantial competent evidence of the record, pursuant to the District of Columbia Superior Court Rules of Civil Procedure Agency Review.
126.12A medical provider or claimant may not appeal a decision of a utilization review organization to the OHA without first requesting reconsideration under §§ 126.8 and 126.9.
126.13 The District of Columbia government shall pay the cost of a utilization review.