Utilization Review Request
Utilization Review Request Form. This is a Pennsylvania form and can be use in Workers Comp.
Tags: Utilization Review Request, LIBC-601, Pennsylvania Workers Comp,
LIBC-601 REV 05-11 INSTRUCTIONS FOR COMPLETING UTILIZATION REVIEW REQUEST Pursuant to the provisions of the Workers’ Compensation Act (Act) and 34 Pa. Code Chapter 127 Medical Cost Containment Regulations, Utilization Review (UR) of all treatment provided by a health care provider under the Act may be subject to UR at the request of an employee, employer or insurer. Persons requesting a UR must provide all information requested on the attached Utilization Review Request form. Please complete this form carefully and accurately and MAIL the original UR Request along with any attachments to: Commonwealth of Pennsylvania Department of Labor and Industry Bureau of Workers’ Compensation Medical Treatment Review Section 1171 South Cameron Street, Room 310 Harrisburg, PA 17104-2597 Copies of the original UR Request along with any attachments must also be mailed to the employee, all providers under review, the insurer/employer and all counsel. For any questions regarding the filing of this UR Request, please contact the Medical Treatment Review Section at 717-772-1914. The UR Request must be filled out completely. All information is required. Please enter “NONE” where appropriate. Please Type or Print clearly. 1. Request filed on behalf of: Check the appropriate box. 2. Employee Information: E nter a ll r equested information. 3. Attorney for employee: Enter all requested information. 4. Employer information: E nter al l r equested information. 5. Insurer or self-insured employer’s third party administrator (TPA): Enter a ll r equested information, including the 4 digit Bureau Code of the insurer or self-insured employer (available at www.dli.state.pa.us). 6. Attorney for insurer/employer: Enter all requested information. 7. Provider(s) under review: Enter the full name, complete ad dress an d telephone num ber of all providers who rendered or will render the treatment(s) or services(s) for which you are requesting U R. R emember t hat w hen the treatment or service to be reviewed is anesthesia i ncident to s urgical pr ocedures, diagnostic t ests, pr escriptions or dur able medical equipment, the request for UR must identify t he provider who m ade t he r eferral, ordered or pr escribed t he t reatment or s ervice as the provider under review. Further, p lease not e t hat you m ay only r equest review of i ndividual providers (i.e., p hysician, chiropractors, et c.), and not f acilities. While facilities are of ten “ licensed” ( i.e., hospitals,) only the actual providers who treat patients may be reviewed. I f t he t reatment which you wish to review constitutes a continuum of care, please identify all providers who rendered such treatment. Finally, i f m ultiple providers r endered t reatment under t he di rection or s upervision of a pr ovider with greater knowledge, education or responsibility for patient care, kindly identify both the i ndividual p roviders and t he directing/supervising provider. 8. Treatment to be reviewed: Specify ONLY the treatment or health c are service to be r eviewed (e.g. “Facet i njections l umbar spine”),and identify t he s tart dat e and en d dat e of treatment(s) which you wish to submit to UR. If the en d dat e i s i ndeterminate, pl ease ent er “ongoing”. I f r equesting a pr ospective r eview, simply s tate “ prospective”. Do not i nclude an y other i nformation, s uch as billing issues, previous U Rs, or ot her c omments w hich m ay influence a reviewer. Such comments will not be forwarded to a reviewer. 9. Billing Dates for retrospective review: A U R request m ust be filed within 3 0 da ys of t he insurer/employer’s receipt of the bill and medical report relating to the treatment under review. If you h ave not r eceived a bi ll and/ or m edical report f or t he t reatment under r eview or i f t his request is f iled by the em ployee e nter “ none”, otherwise, for each provider under review, enter the dat e upon w hich the i nsurer/employer received the bills and reports. 10. Payment pending WCJ decision: If pa yment for t he t reatment under r eview was w ithheld pending a decision o n a c laim or r einstatement petition, p lease so i ndicate an d enter t he circulation d ate of t he dec ision a warding benefits. 11. Other treating providers: On a separate sheet, enter the full name, license, specialty, complete address and valid telephone number of all other health care providers who rendered treatment or services f or t he work-related i njury. Please do not include non-treating providers such as those who h ave p erformed i ndependent m edical examinations. 12. Requesting party or representative: T ype or print your name, address and telephone number. You MUST sign the UR Request. 13. Proof of Service: Provide the date the UR Request was signed and mailed to all parties. If you am end or “ re-file” t his r equest, you m ust update the Proof of Service Date. LIBC-601 REV 05-11 (Page 1) UTILIZATION REVIEW REQUEST Department of Labor & Industry Bureau of Workers’ Compensation 1171 S. Cameron Street, Room 310 Harrisburg, PA 17104-2597 601 0511-1 Review Number (for Official Use Only) The UR Request must be Filled out Completely (follow printed instructions): ALL INFORMATION IS REQUIRED. 1. Filed on Behalf of: Employee Insurer/Employer 3. Employee Attorney Information: 2. Employee Information: First Name: Firm Name: Last Name: First Name: Address: Last Name: City/State/Zip: Address line 1: Date of Birth: Address line 2: Date of Injury: City/State/Zip: SSN: 5. Insurer or Self Insured TPA Information 4. Employer Information Four (4) Digit Bureau Code: Employer Name: (*Required: See BWC website for Bureau Codes) Address line 1: Insurer/TPA Name: Address line 2: Address line 1: City/State/Zip: Address line 2: City/State/Zip: 6. Insurer/Employer Attorney Information: Claim Rep Name: Firm Name: Claim Rep Telephone: First Name: Ins. Claim Number: Last Name: Address line 1: Address line 2: City/State/Zip: PROVIDER 1: First Name: Office Address: City/State/Zip: Telephone ( ) Treatment to be Reviewed: Start/End Date: Bill Rec’d ** Box 7 - 10 Provider/Treatment information Please see instruction page. Last Name: License/Specialty None PROVIDER 2: First Name: Office Address: City/State/Zip: Telephone ( ) Treatment to be Reviewed: Start/End Date: Bill Rec’d WCJ Circulation Date: Report Rec’d None Last Name: License/Specialty None WCJ Circulation Date: Report Rec’d None PROVIDER 3: First Name: Office Address: City/State/Zip: Telephone ( ) Treatment to be Reviewed: Last Name: License/Specialty Start/End Date: Bill Rec’d None PROVIDER 4: First Name: Office Address: City/State/Zip: Telephone ( ) Treatment to be Reviewed: WCJ Circulation Date: Report Rec’d None Last Name: License/Specialty Start/End Date: Bill Rec’d None PROVIDER 5: First Name: Office Address: City/State/Zip: Telephone ( ) Treatment to be Reviewed: WCJ Circulation Date: Report Rec’d None Last Name: License/Specialty Start/End Date: Bill Rec’d None WCJ Circulation Date: Report Rec’d None (Pursuant to §127.404(b) the request for UR shall be filed within 30 days of receipt of the bill and report for the treatment at issue) #11. Other Treating Providers: On an additional sheet, please list any other treating providers for this claimant. Include first and last name, license and specialty, full address and telephone number for each provider. #12. Requesting party or Representative Signature: Typed/Printed Name of Requesting Party or Representative: Address: City/State/Zip: Telephone Number: ( ) email address: #13. Proof of Service: I hereby certify that on this day I have mailed a copy of this request to all parties and their attorneys, if known, including the provider(s) under review. ANY FALSE STATEMENT CONTAINED IN THIS UTILIZATION REVIEW REQUEST MAY BE THE SUBJECT OF PROSECUTION UNDER ARTICLE XI OF THE ACT (RELATING TO INSURANCE FRAUD), OR 18 Pa. C.S. §4903 (RELATING TO FALSE SWEARING). Proof of Service Date (MUST be updated if request is amended/re-filed): NOTE: Send the original UR Request to: Bureau of Workers’ Compensation, Medical Treatment Review Section Room 310 1171 South Cameron Street, Harrisburg, PA 17104-2597 DO NOT attach depositions, medical records, IME reports or any other document not specifically requested to the UR Request Form. Any attachments not specifically requested will NOT be forwarded to the URO, and will NOT be returned. The Bureau will destroy/shred all attachments not requested. Auxiliary aids and services are available on request to individuals with disabilities. Equal Opportunity Employer/Program LIBC-601 REV 05-11 (Page 2) 601 0511-2