Section 7-232. UTILIZATION REVIEW

 

232.1Any 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.

 

232.2A utilization review organization or individual used pursuant to the Act shall be certified by the Utilization Review Accreditation Commission.

 

232.3The employee, employer or the Office may initiate the review, accepting as a given the diagnosis of injury, 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.

 

232.4The 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, employer and the Office.

 

232.5A utilization review report which conforms to the provisions of §232.4 of this chapter may 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 or disability.

 

232.6If the medical care provider disagrees with the opinion of the utilization review organization or individual, the medical care provider may submit a written request to the utilization review organization or individual for reconsideration of the opinion. The request shall contain reasonable medical justification for the request and shall be made within sixty (60) calendar days from actual receipt of the utilization review report.

 

232.7If a dispute arises between the medical care provider, employee, or employer on the issue of necessity, character, or sufficiency of the medical care or service or fees charged by the medical care provider, the dispute shall be resolved by the Director upon application for a hearing. Any party adversely affected by the Director's Decision shall appeal to the D.C. Court of Appeals. Copies of all reports shall be furnished to all interested parties.

 

232.8The cost of a utilization review shall be paid by the employer, if the employee seeks the review and is the prevailing party.

 

source

Notice of Final Rulemaking published at 41 DCR 3213 (June 3, 1994).