Utilization Review Agent Complaint Form
Utilization Review Agent Complaint Form. This is a Massachusetts form and can be use in Workers Comp.
Tags: Utilization Review Agent Complaint Form, 133A, Massachusetts Workers Comp,
FORM 133A DIA Board # (If Known): The Commonwealth of Massachusetts Department of Industrial Accidents 600 Washington Street - 7th Floor, Boston, Massachusetts 02111 Info.Line (800) 323-3249 ext: 470 in Mass. Outside Mass.- (617) 727-4900 ext. 470 http://www.mass.gov/dia Page 1 of 2 UTILIZATION REVIEW AGENT AND QUALITY ASSESSMENT PROGRAM COMPLAINT FORM 6.01: Scope and Authority: 452 CMR 6.0 et seq. is promulgated pursuant to M.G.L. ch. 152 §§5, 13 and §30 as most recently amended by St. 1991, c 398. 452 CMR 6.0 et seq. shall apply to all claims, irrespective of date of injury for health care services rendered on or after October 1, 1993. 452 CMR 6.0 et seq. requires workers' compensation insurers to undertake utilization review, sets forth the nature of utilization data that must be reported to the Department of Industrial Accidents, sets forth the methods for quality assessment that will be used by the Department of Industrial Accidents and sets forth the mechanisms that DIA will use to ensure compliance with 452 CMR 6.0 et seq. Please check the appropriate box below: The UR Agent/Insurer has not: A. rendered an Introductory Letter that includes the rights and responsibilities of the employee and the UR Agent B. rendered a Notice of any kind to either the Employee or the Provider C. rendered a notice of Adverse Determination to both Employee and Provider [6.04(4)(b)] D. rendered a notice of Adverse Determination to both Employee and Provider within the time constraints [6.04(4)(b)] E. made its Appeal-Level Determination within the time constraints [6.04(4)(c)] F. provided a review by a Same-School Practitioner when rendering an appeal-level determination [6.04(4)(c)1] G. provided the Review Criteria used to make an adverse determination [6.04(4)(c)] H. provided all the Reasons used to reach an adverse determination [6.04(4)(c)] I. provided the Employee with a notice of Rights and Responsibilities and Appeal procedure [6.04(2)(d)] J. complied with Telephone Requirements for UR Agent availability and staffing [6.04(4)(d)] K. contracted with an approved agent to provide UR or to develop their own UR review program approved by the DIA to review both outpatient and inpatient health care services approved through the DIA [6.04] L. other:_______________________________________________________________________________________________ TO FILE A COMPLAINT, PLEASE PROVIDE THE FOLLOWING INFORMATION: TODAY'S DATE:_____________________________ NAME OF PERSON FILING COMPLAINT:______________________________________________________________________ ADDRESS:_________________________________________________________________________________________________ CITY/STATE/ZIP:___________________________________________________________________________________________ TEL: (_____)_________________________ YOU ARE: (Please Check One): PROVIDER EMPLOYER EMPLOYEE OTHER PLEASE NOTE: You are required to inform the injured employee of this filing. The injured employee will be cross-copied on all responses and exhibits received during the course of the complaint investigation INJURED EMPLOYEE'S NAME: _____________________________________________________________________________ ADDRESS:_________________________________________________________________________________________________ CITY/STATE/ZIP:____________________________________________________TEL: (______)__________________________ Reproduce as Needed (over) Form 133A- Revised 6/2006 American LegalNet, Inc. www.USCourtForms.com FORM 133A - UR AGENT COMPLAINT FORM Page 2 of 2 EMPLOYER:_______________________________________ INSURER:_____________________________________________ ADDRESS:_________________________________________ ADDRESS:_____________________________________________ CITY/STATE/ZIP:___________________________________ CITY/STATE/ZIP:_______________________________________ PLEASE PROVIDE THE FOLLOWING INFORMATION ABOUT THE UTILIZATION REVIEW AGENT: NAME OF UR COMPANY: __________________________________________________________________________________ NAME OF UR CONTACT PERSON: ____________________________________________________________________________ ADDRESS: ___________________________________________________________________________________________ CITY/STATE/ZIP: ___________________________________________________________________________________________ TELEPHONE: (________)_________________________ DATE(S) OF CONTACT: ____________________________ ____________________________ ____________________________ Using the following space, summarize your complaint about the UR Agent. In addition, attach copies of any other documentation to this form that supports your complaint, including correspondence from the UR Agent, specific dates of contact with the UR Agent, person(s) contacted, etc.: SEND THIS COMPLETED COMPLAINT FORM WITH ATTACHMENT(S) TO: Department Of Industrial Accidents Office of Health Policy 600 Washington Street, 7th Floor Boston, Ma 02111 A COPY OF THIS COMPLAINT AND ALL ATTACHMENTS WILL BE FORWARDED TO THE UR AGENT. American LegalNet, Inc. www.USCourtForms.com American LegalNet, Inc. www.USCourtForms.com