90- 351 C.M.R. ch. 7, § 3

Current through 2024-51, December 18, 2024

Section 351-7-3 - Utilization Review; Procedures

1. When an employer/insurer requests Utilization Review, the employer/ insurer must notify the injured employee that it intends to initiate Utilization Review.

2. Notice to the employee must, at a minimum, contain:

A. An explanation of the reason(s) Utilization Review is being requested;

B. Identification of the Utilization Review Agent that has been selected; and

C. Notice that the injured employee can send a letter to the Utilization Review Agent, within 10 days, explaining why the contested treatment is appropriate.

3. If the employer/insurer fails to send the required notice to the injured worker, the employer/insurer will be precluded from entering the Utilization Review determination into evidence in any subsequent Board proceeding.

4. If the Insurer/Utilization Review Agent makes a request for records, the health care provider may insist the request be submitted in writing. The provider shall in turn provide the requested information within ten (10) business days. A fee for medical records or narratives shall be paid in accordance with Workers' Compensation Board Rule Chapter 5.

5. After each level of Utilization Review, the Utilization Review Agent shall provide notice to the injured employee, the affected health care provider(s), and the employer/insurer of the Utilization Review Agent's determination. This notice must include an explanation of each party's appeal rights.

6. Within one business day of the completion of the final level of Utilization Review, the Utilization Review Agent shall send a report to the injured employee, the affected health care provider, and the employer/insurer. This report must include, at a minimum, the Utilization Review Agent's determination, and the reasons therefore.

7. If the Insurer/Utilization Review Agent determines that the provider of record has made any excessive charges or required unjustified treatment, hospitalization or visits, the health facility or health care provider may not receive payment for those health care services from the Insurer and is liable to return to the Insurer any such fees or charges already collected.

8. Except as ordered pursuant to 39-A M.R.S.A. §206(2)(B), the injured employee is not liable for any portion of the cost of any provided medical or health care services.

90- 351 C.M.R. ch. 7, § 3