Managed-Care Utilization Review Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Managed-Care Utilization Review Form. This is a Kentucky form and can be use in Workers Comp.
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Tags: Managed-Care Utilization Review, Kentucky Workers Comp,
MANAGED-CARE/UTILIZATION REVIEW
Has your organization contracted with an approved Managed Care Organization to provide
medical services to injured employees? KRS 342.020(3)
If so, please provide the following information:
Name: ________________________________________
Address: ______________________________________
Phone No.: ____________________________________
E-Mail Address: ________________________________
If your organization has not contracted with an approved Managed Care Organization to provide
medical services to injured employees, who provides Utilization Review and Medical Bill Audit
for medical treatment rendered to injured workers? 803 KAR 25:190 § 3(3)(5)
Name: ________________________________________
Address: ______________________________________
Phone No.: ____________________________________
Fax No.: ______________________________________
E-Mail Address: ________________________________
Please Note : It is the self- insured employer’s responsibility to inform the Kentucky Office of
Workers’ Claims when policy changes relating to the administration of claims, managed-care
and utilization review have been implemented within a respective employer’s self- insurance
program.
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